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(Take  t!  from  SaunJfrs'  Hand  Atlas) 


SYPHILIS  IN  DENTISTRY 


BY 

L.  BLAKE  BALDWIN,  M.  D. 

CHICAGO,    ILL. 

Professor  of  Dermntologv  and  Venereal  Diseases,  Post-OraduaU 
Medical  School;  Professor  Clinical  Dermatology,  Medical 
Department,    University  of  Illinois    {College  of  P. 
and  S.) ;  Attendiiig  Dermatologist  to  Cook  County 
Hospital  and  the  Provident  Hospital;  Presi- 
dent of  the  Samaritan  Hospital;    Fel- 
low Chicago  Academy  of  Medi- 
cine; Etc.,  Etc.,  Etc.,  Etc. 


EZRA  READ  EARNED,  M.  D. 

CHICAGO,    ILL. 

American  Association  for  the  Advancement  of  Science;  Chicago 
Academy  of  Science;  American    Medical   Associa- 
tion;   Illinois    State   Medical    Society; 
Chicago  Medical  Society,  Etc. 


CHICAGO 
H.     COLEGROVE 
1903 


Copyrighted 

BY 

L.  BLAKE  BALDWIN 
1903 

"To  our  brothers  in  arms;',  the  memhers  of  the  dental 
profession,  this  book  is  respectfully  dedicated,  witli  the 
earnest  hope  that  it  may  help  in  the  recognition  and 
alleviation  of  one  of  the  gravest  diseases  of  mankind. 


Digitized  by  tine  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/syphilisindentisOObald 


CONTENTS. 


Part 

I. 

Part 

II. 

Part 

III. 

Part 

IV. 

Part 

V. 

Part 

VI. 

Part 

VII. 

Part 

VIII. 

Part 

IX. 

Part 

X. 

Part 

XI. 

Part 

XII. 

Part 

XIII. 

PAGE 

Introduction    -           -           -  -      7 

Historical  -           -           -  -          15 

Nomenclature             -           -  -     21 

Bacteriology          -           -  -          27 

Infection           -           -           -  -    35 
The  Initial  Lesion  and  Pathology    49 

Secondary  Manifestations  -          63 

Mucous  Patches          -           -  -    75 

Tertiary  Syphilis            -  -          85 

Interstitial  Gingivitis         -  -    95 

Differenial  Diagnosis    -  -        101 

Illustrative  Cases    -           -  -  107 

Medico-Legal  Aspects    -  -        117 


SYPHILIS   IN  DENTISTRY. 


PART  1. 


INTRODUCTION. 

In  many  brancliesi  of  medical  science, 
progress  and  advancement  have  been 
great — the  achievementsi  in  the  depart- 
ments of  surgery  and  bacteriology  have 
out-rivaled  the  dreams  of  the  enthusiast  of 
a  few  years  ago,  but  very  much  remains  to 
be  done.  Every  progressive  man  should 
take  a  part  in  unraveling  the  many  mys- 
teries in  medicine  and  its  allied  sciences. 
The  modern  dentist,  as  well  as  the  physi- 
cian, must  be  "up-to-date,"  if  it  is  his  ambi- 
tion to  remain  in  the  front  rank  of  his  pro- 
fession. 

The  authors  believe  that  dentists  have 
nearly  as  much  to  do  with  the  recognition 
and  prevention  of  syphilis  as  have  physi- 
cians and  surgeons,  and  propose  that  this 
work  shall  call  the  attention  of  those  prac- 
7 


8  SYPHILIS  IN  DENTISTRY. 

ticing  dental  surgery  to  their  opportun- 
ities and  responsibilities. 

"The  deaths,  sufferings  and  expense  due 
to  syphilis  are  incomprehensible  and 
appalling,  and  the  rotting  poison  is  still 
working  ruin  in  every  city,  village  and 
hospital  in  the  land,  creating  the  inevit- 
able impotence,  paralysis  and  death  which 
so  surely  follow  in  its  train." 

"Ignorance  of  the  law  does  not  excuse." 

How  culpable,  then,  is  he  who  shall  even 
unwittingly  infect  an  innocent  human  be- 
ing with  this  dreadful  disease,  and  how 
derelict  in  his  duty  is  he  who  shall  fail  in 
detecting  the  disease  in  others  who  may 
come  to  him  for  advice  and  assistance. 

Dentists,  as  a  class,  give  very  little  con- 
sideration to  this  very  important  subject, 
but  they  should  give  it  the  most  careful 
study,  as  we  shall  endeavor  to  point  out. 

They  should  recognize  the  mouth  le- 
sions of  syjihilis,  so  that  they  can  guard 
against  infecting  themselves,  and  so  that 
they  may  not  infect  others,  by  instruments 
used  in  a  syphilitic  mouth. 

If  they  do  not  recognize  syphilis  in  a 
patient's  mouth,  how    many    people    may 


INTRODUCTION.  9 

they  expose  before  some  one  else  diagnoses 
the  condition  for  tbem,  and  calls  a  halt  in 
the  deadly  work? 

To  briefly  point  out  the  prevalence  of 
syphilis  in  the  mouth,  etc.,  let  us  call  yoTir 
attention  to  the  following  facts: — 

Fournier  collected  1,124  cases  of  extra- 
genital chancre,  of  which  847  cases  were 
in  the  region  of  the  head,  most  of  them 
located  about  the  lips. 

Bulkley  gives  a  total  of  9,058  extra- 
genital infections,  and  the  site  of  the  tonsil 
is  sixth  in  frequeiDGif.  The  tonsils  and 
throat  together  are  given  as  the  site  of  571 
cases,  which  place  the  throat  as  fourth  in 
frequeneif,  being  exceeded  only  by  the  lips, 
breast  and  nipples. 

Kyle  says  that  next  to  the  genitalia,  the 
tonsil  and  pharynx  are  the  most  frequent 
sites  for  the  primary  lesion. 

Many  cases  of  chancre  of  the  tonsil  are 
overlooked,  for  they  have  little  resem- 
blance to  cancers  which  occur  on  the 
genitals.  The  source  of  syphilis  in  the 
mouth  is  varied:  kissing,  infected  utensils, 
the  pipe  or  cigar,  and  dental  instruments, 
convey  the  infection. 


10  SYPHILIS  IN  DENTISTEY. 

The  diagnosis  of  secondary  and  tertiary 
syphilis  of  the  throat  is  easy,  but  that  of 
primary  involvement  is  difficult. 

Many  case  histories  illustrative  of  these 
facts  could  be  presented  here,  but  experi- 
ence has  shown  that  the  syphilitics  coming 
under  the  dentist's  care  are  not  those 
.suffering  from  extra-genital  ,chancre,  but 
those  presenting  mucous  patches,  com- 
monly known  as  smokers'  patches,  which 
resemble,  in  some  cases,  ulcerative  stom- 
atitis. In  these  patches  lie  the  danger  to 
the  dentist  and  his  patients.  (1)  They 
are  as  infectious  as  the  initial  lesion.  (2) 
They  occur  in  ninety  cases  out  of  a  hun- 
dred during  the  first  year  of  the  disease. 
(3)  Very  few  dentists  are  able  to  recog- 
nize the  condition.  (4)  If  patients  are 
asked  if  they  have  syphilis,  they  will  deny 
it;  some  because  they  do  not  know  it; 
others,  because  they  wish  to  conceal  the 
fact. 

El  R.  OarDenter,  in  the  "Dental  Review," 
says:  "The  undeniable  fact  that  there 
exists  such  a  gross  ignorance  on  this  sub- 
ject among  our  profession  is  undoubtedly 
due  to  the  lack  of  professional  informa- 


INTEODUCTION.  11 

tion  in  regard  to  it.  While  it  should  be 
considered  as  thoughtfully  and  compre- 
hensively as  other  diseases  of  far  less 
prevalence,  it  is  not  intelligently  recog- 
nized in  the  curriculum  of  any  dental  col- 
lege in  this  country.  That  this  fact  is  true 
is  as  indisputable  as  its  existence  is  repre- 
hensible." 

If  this  little  book  stimulates  its  readers 
to  a  closer  study  of  this  terrible  disease, 
whose  only  visible  expression  may  be 
entirely  in  the  mouth,  and  serves  to 
awaken  a  clearer  perception  of  the  great 
responsibilities  of  the  dental  profession  in 
the  care  of  public  health,  and  thereby  con- 
tributes to  the  more  thoughtful  study,  and, 
mayhap,  a  little  tO'  the  control  of  syphilis, 
it  will  have  gratified  the  hopes  and  ambi- 
tions of  the  authors. 

For  hearty  encouragement  and  valu- 
able assistance,  the  authors  gratefully 
acknowledge  their  indebtedness  to  A.  E. 
Baldwin,  M.  D.,  D.  D.  S.;  E.  S.  Talbot,  M. 
D.,  D.  D.  S.;  J.  N.  Grouse,  D.  D.  S.;  G.  W. 
Cook,  D.  D.  S.;  James  G.  Kiernan,  M.  D., 
and  to  Dr.  A.  H.  Ohmann-Dumesnil,  for 
his  kind  permission  to  use  his  researches 


13  SYPHILIS  IK  DENTISTRY. 

in  the  subject  of  Interstitial  Gingivitis,  in 
Part  X.,  asi  well  as  toi  other  writers  on 
similar  or  allied  subjects,  whose  works 
have  been  levied  upon  in  the  preparation 
of  this  book. 


PART   II. 

,    =  HISTORICAL. 

"Nihil  sub  sole  novum"— Eccles.,  I,  10. 

While  a  dissertation  upon  the  antiquity 
of  syphilis  is  not  properly  a  part  of  a  work 
of  this  character,  still,  in  view  of  the  fact 
that  the  age  and  source  of  syphilis  have 
lately  been  made  the  subject  of  much  vehe- 
ment argument  pro  and  con,  we  desire  to 
register  our  belief  in  the  great  antiquity 
of  this  disease,  and  to  call  attention  to  a 
few  facts  in  support  of  our  contention. 

In  the  Mus^e  d'Histoire  Naturelle  and 
the  Mus^e  d'Anthropologie,  in  Paris, 
France,  are  skeletons  of  the  pre-historic 
man  of  Europe,  whose  bones  bear  the  un- 
deniable traces  of  syphilitic  alterations, 
some  of  which  are  perfectly  typical. 

In  ani  interesting  article,  published  by 

J.  Parrott,  in  the  "Revue  Scientifique,"  in 

1882,    entitled    "Une  Maladie     Prehistor- 

ique/'  the  author  produces  some  incontro- 

15 


16  SYPHILIS  IN  DENTISTRY. 

yertible  facts  in  support  of  the  antiquity 
of  syphilis.  We  quote:  "Upon  the  teeth 
the  imprints  of  hereditary  syphilis  are 
tenacious  and  characteristic. 

"They  often  preserve  their  original 
appearance,  not  only  during  the  life  of 
the  individual,  but  after  death." 

No  other  disease,  says  Parrott,  can  pro- 
duce them,  so  that  their  existence  justifies 
us  in  affirming  that  the  subject  affected 
with  such  remains  was  a  syphilitic. 

He  there  speaks  of  the  lower  jaw  of  a 
young  Frank  of  the  Merovingian  epoch, 
found  in  a  sepulchre  at  Brenej  (Aisne). 
The  teeth  in  this  jaw  clearly  show  lesions, 
such  as  are  produced  by  hereditary  syph- 
ilis, and  hence  this  disease  existed  in 
France  certainly  before  the  seventh  cen- 
tury. 

In  the  celebrated  medical  treatise,  Nuei- 
King,  compiled  by  the  Chinese  Emperor, 
Hoang-ty,  at  a  time  which  corresponds  to 
2637  B.  C,  there  are  descriptions  of  a 
disease  which  exactly  corresponds  tO'  what 
we  know  as  syphilis,  and  this  treatise 
speaks  of  it  as  a  "very  ancient  disease." 
Ancient,  4540  years  ago! 


HISTOEICAL.  17 

The  ancient  books  of  India  (the  Bible 
of  India),  the  Yedas,  is  a  collection  of 
writings,  religious,  literary  and  scientific, 
the  latter  part  being  called  Ayurreda. 

The  beginning  of  the  period  of  which  the 
Ayurveda  treats  is  lost  in  the  immensity 
of  time,  but  is  believed  to  end  about  the 
year  1000  B.  C,  or  2900  years  ago. 

It  has  many  passages  which  treat  of  cer- 
tain diseases,  whose  identity  with  modern 
syphilis  it  were  folly  to  deny. 

The  works  of  Hippocrates,  T^Titten 
either  by  himself  or  his  iDupils,  were  com- 
posed about  the  middle  of  the  fifth  cen- 
tury B.  C,  for  the  ''Father  of  Medicine" 
practiced  at  Cos  in  the  year  460  B.  C. 

In  Hippocrates'  works  there  cannot  be 
found  any  exact  description  of  syphilis,  in 
the  strict  acceptance  of  the  term,  but  there 
are  hosts  of  allusions  which  cannot  refer 
to  anything  else,  as  many  writers  admit. 

Galen,  the  Greek  physician,  who  was 
born  at  Pergamos,  A.  D.  131,  refers  many 
times  to  lesions  which  cannot  but  spell 
syphilis,  and  especially  does  he  speak  of 
peculiar  pains  of  the  periosteum,  which 
were  so  deep  and  constant  that  the  patient 


18  SYPHILIS  IN  DENTISTEY. 

believed  the  bones  themselvesi  were  the 
seat  of  the  pains,  which  were  undoubtedly 
syphilitic. 

Pliny,  the  celebrated  Ronian,  wrote 
upon  diseases  of  the  Eomans,  which  must 
be  diagnosed  as  tertiary  lesions  of  syphilis. 

The  Bible  is  full  of  fairly  accurate  de- 
scriptions of  syphilis.  But  enough;  to 
those  whose  inclinations  are  to  pursue 
this  subject  more  fully,  we  heartily  recom- 
mend a  perusal  of  the  interesting  work  of 
Dr.  Buret  ("Syphilis  in  Ancient  and 
Modern  Times"),  to  which  we  are  indebted 
for  liberal  quotations. 


PART  III, 


NOMENCLATURE. 

The  word  sypliilis  is  now  almost  univer- 
sally employed  to  designate  a  definite 
disease  which  may  be  recognized  by  cer- 
tain more  or  less  constant  signs  and 
symptoms. 

It  was  first  used  in  a  celebrated  poem 
by  Jerome  Frascator,  written  about  the 
year  1521,  and  entitled  "Syphilis  Sive 
Morbus  Gallicus."  In  this  poem  it  is  sup- 
posed that  a  shepherd  named  Syphilus  has 
offended,  and  is  punished  by  Apollo,  who 
sent  him  a  disease  of  the  genitals,  and 
which  the  inhabitants  of  the  country  called 
"the  disease  of  Syphilus." 

Before  this,  the  most  common  name  was 
Morbus  Gallicus,  or  disease  of  the  Gauls, 
meaning  disease  of  the  French.  Later  on, 
as  points  of  resemblance  between  the  pus- 
tules of  syphilis  and  variola  were  noted, 
the  Morbus  Gallicus  was  called  the  "gTo^se 

21 


23  SYPHILIS  IN  DENTISTRY. 

verole"  (big  pox),  and  to  avoid  confusion, 
variola  was  called  "petite  verole"  (small 
pox),  by  wbicb  nam©  it  is  now  universally 
known. 

Another  nam©  also  in  quite  common  use, 
Lues  Venerea,  was  first  proposed  in  1527 
by  JacqueSi  de  Bethencourt.  There  have 
been  many  names  applied  to  certain  con- 
ditions which  were  undoubtedly  of  a  syph- 
ilitic character,  and  this  very  multiplicity 
of  names  has  confused  investigators  into 
the  history  of  the  disease. 

Some  of  these  names  ar©  yet  used  occa- 
sionally, although  practically  superseded 
by  the  more  common  terms,  syphilis  and 
lues. 

In  his  study,  "Der  Ursprung  der  Syph- 
ilis," Dr.  Bloch  has  collected  the  various 
names  given  to  syphilis,  and  has  classified 
them,  as  follows: 

34  names  according  to  the  supposed 
country  of  origin. 

46  names  referring  to  the  physical 
symptomsi. 

18  names  combining  the  two  foregoing. 

12  names  after  the  part  of  the  body 
afflicted. 


NOMENCLATUEE.  23 

34  names  according  to  cause  and  extent. 

12  names  in  general. 

14  names  after  saints. 

24  names  used  especially  in  Spain. 

26  names  used  especially  in  Italy. 

110  names  used  especially  in  France. 

46  names  used  especially  in  Germany. 

IT  names  used  especially  in  England. 

9  names  used  especially  in  Holland. 

7  names  used  especially  in  Denmark. 

4  names  used  especially  in  Sweden. 

12  names  used  especially  in  Portugal. 

11  names  used  especially  in  Eussia. 

37  names  used  especially  in  Poland. 

The  havoc  which  the  disease  wrought 
among  the  morally  and  physically  defect- 
ive people  of  Europe  struck  their  imagina- 
tion powerfully,  and  the  following  are  a 
few  of  the  names  which  they  gave  to  what 
we  know  as  syphilis : 

Malum  francicum. 

Malum  francigenarum. 

Malum  francorum. 

Malum  Castellanum. 

Malum  Indicum. 

Malum  pustularum. 

Malum  St.  Menti. 


24  SYPHILIS  IN  DENTISTRY. 

Malum  franciae. 

Malum  francosiae. 

Malum  Americanum. 

Mai  de  St.  Main. 

Mai  de  simiente. 

Mai  dei  Naples. 

Mai  Celtico. 

Mai  St.  Gillain. 

Mai  de  lai  Isla  Espanola. 

Mai  de  los.  Castillanos. 

Mai  gallico. 

Lo  male  de  lo  Brosule. 

Das  Venerisclie  Uebel. 

Malefrancum. 

Malum  Neapolitanum. 

Malum  aphrodisiacum. 

Mai  Sr.  Kemi. 

Mai  Serpentino. 

II  Male  venereo'. 

Grosse  Verole  (big  pox). 

Syphilis  is  now  generally  regarded  as 
the  most  acceptable  term,  and  is  almost 
universally  used  in  scientific  works. 


PART  IV. 


BACTERIOLOGY. 

Syphilis  is  a  chronic  infectious  disease, 
produced  by  a  specific  organism  not  yet 
definitely  isolated,  and  exhibiting  char- 
acteristic early  local  and  late  constitu- 
tional manifestations. 

Lustgarten  demonstrated  in  syphilitic 
tissues,  and  in  secretions  from  syphilitic 
ulcers  a  bacillus,  somewhat  resembling  the 
tubercle  bacillus,  but  differing  from  it  in 
being  more  frequently  curved,  and  in  hav- 
ing clubbed  ends,  as  well  as  its  behavior 
when  treated  with  stains  and  acids.  After 
staining  by  the  Ziehl-Neelsen  method,  the 
tubercle  and  lepra  bacilli  are  not  decolor- 
ized by  nitric  and  hydrochloric  acids, 
unless  subjected  to  their  action  for  a  long 
time,  while  the  Lustgarten  bacillus  readily 
yields  its  stain  when  subjected  to  these 
reagents. 

Since     Lustgarten's     announcement,     iu 

2.7 


28  SYPHILIS  IN  DENTISTEY. 

1884,  of  the  cliseovery  of  a  "bacillus  of 
sypiiiiis,"  scientific  men  have  been  at  work 
almost  constantly  upon  the  question  of 
the  microorganism  of  syphilis.  The  results 
until  last  year  have  been  entirely  negative. 
Lustgarten's  work  was  never  completed  to 
anyone's  satisfaction,  and  it  has  never 
been  proved  that  Lustgarten's  bacillus  is 
not  identical  with  the  bacillus  smegmatis. 
Eve  and  Lingard,  in  1886;  Disse  and 
Taguchi,  in  the  same  year,  and  Golasz,  in 
1894,  have  all  failed  to  establish  their 
claims,  or  gain  any  serious  recognition. 

In  July,  1901,  however,  an  announce- 
ment of  unusual  significance  and  promise 
was  made  before  the  Paris  Academy  of 
Medicine,  by  Justin  de  Lisle  and  Louis 
Jullien  (Bulletin  de  I'Academie  de  Medi- 
cine de  Paris,  July  2,  1901).  De  Lisle 
and  Jullien  chose  as  the  starting  point  of 
their  investigation  the  classic  experiment 
of  Pellizari,  in  1868.  By  Pellizari,  it  will 
be  recalled,  three  3^oung  men  were  success- 
ively inoculated  from  a  woman  "in  full 
flower,"  with  the  secondary  accidents  of 
untreated  syphilis.  The  first  took  syphilis; 
the  second  and  third  did  not.    No  explana- 


BACTEEIOLOGY.  39 

tion  of  this  fact  was  apparent  till  the 
recent  discoyery  of  the  bactericidal  alexin 
liberated  from  the  leucocytes  in  clotted 
blood,  which,  as  appeared  to  the  writers 
jnst  mentioned,  might  haye  killed  the 
syphilitic  germ  in  the  interyal  elapsing 
between  the  first  and  second  inoculations. 

Proceeding  on  this  assumption,  de  Lisle 
and  Jullien  deyised  a  method  of  growing 
the  suspected  organism  in  blood  depriyed 
of  its  leucocytes,  and  hence  of  its  alexin^ 
immediately  after  drawing.  An  exact 
method  of  procedure  was  at  first  diflftcult, 
but  the  writers  finally  succeeded  in  iso- 
lating a  bacillus,  which  grows  on  numer- 
ous media,  stains  well  with  gentian  yiolet 
and  carbol-fuchsin,  poorly  with  methylene 
blue,  and  not  at  all  by  the  Gram  method. 
The  germ  grows  remarkably  on  amniotic 
fluid. 

The  bacillus  is  described  as  being  essen- 
tially polymorphous,  its  aspect  yarying 
from  that  of  a  short  bacillus,  measuring 
five  to  eight  microns  in  length  and  15-100 
to  3-10  microns  in  thickness,  to  that  of  a 
very  long  filament.  Its  extremities  are 
vaguely    rounded,     but    not     club-shaped. 


30  SYPHILIS  IN  DENTISTEY. 

Under  the  microscope,  the  bacillus  is  seen 
to  be  very  lively  and  performs  evolutions. 
It  is  easily  colored  by  the  ordinary  staining 
materials,  but  care  must  be  taken  not  to 
dry  it  in  the  flame  or  at  a  higher  tempera- 
ture than  60°  C.  (140°  F.).  Alcoholic 
ether,  or  a  solution  of  osmic  acid,  may  be 
employed  mth  advantage.  Sown  or  culti- 
vated in  bouillon,  the  latter  becomes  tur- 
bid within  twenty-four  hours.  After  four 
or  five  days  a  thin  veil  is  perceptible,  but 
neither  spreads  nor  thickens.  Gelatin  is 
slowly  liquefied  by  it.  If  the  gelatin  be 
scratched  and  the  bacillus  deposited,  nei- 
ther the  conical  nor  funnel-shaped  forms 
are  determined.  The  liquid  in  the  tube  be- 
comes turbid  and  flaky,  with  a  gTeenish 
tint;  the  gelatin  is  not  colored,  and  the 
surface  remains  even.  Upon  layers  of  soft 
gelatin,  rounded,  grayish,  irregular  bor- 
dered colonies  of  microbes  appear  within 
four  or  five  days,  and  in  from  twenty  to 
thirty  days  the  whole  gelatin  is  liquefied. 
Upon  ordinary  gelose  and  glycerinated 
gelose,  as  also  peptonized  gelose,  a  creamy 
coating  is  formed,  always  moist  and  of  a 
faint  greenish  hue. 


BACTERIOLOGY.  31 

Cultures  injected  into  laboratory  ani- 
mals caused  rapid  death,  but,  as  might 
have  been  expected,  post-mortem  libera- 
tion of  alexins  killed  the  germs  and  the  ca- 
davei^  were  found  always  sterile. 

Most  interesting  and  important  fact  of 
all,  the  blood  of  cases  of  secondary  syph- 
ilis, untreated  with  mercury,  made  a  per- 
fect agglutination  of  the  cultures,  while 
no  other  blood  was  ever  found  to  do  so. 
Inoculation  of  the  germ  into  syphilitic  sub- 
jects gave  no  result.  We  understand  that 
Dr.  de  Lisle  has  of  late  greatly  improved 
his  method  of  isolating  the  bacillus  from  the 
blood,  and  that  he  expects  shortly  to  make 
another  and  convincing  communication  on 
the  subject. 

Following  upon  this  paper,  and  appar- 
ently relating  to  the  independent  discovery 
of  the  same  germ,  is  the  paper  of  Dr.  Max 
Joseph  and  Dr.  Piarkowsky,  in  the  Ber- 
liner Klinische  Wochenschrift  for  March 
24  and  31,  1902. 

The  starting  point  of  Dr.  Joseph's  work 
was  the  fact  that  the  sperm  of  a  man  in- 
fected with  secondary  syphilis  retains  its 
capacity  to   transmit  syphilis  to   the  off- 


32  SYPHILIS  IN  DENTISTEY. 

spring  even  after  the  patient  has  been  ap- 
parently long  cured. 

Sterile  sperm  was  inoculated  upon  sterile 
bits  of  fresh  placenta.  On  the  first  day  small 
"dew-drop"  colonies  could  with  difficulty 
be  made  out.  These  subsequently  turned 
gray  and  became  confluent. 

Some  of  the  colonies  contained  staphylo- 
cocci only;  some,  however,  contained  a  ba- 
cillus corresponding  in  many  ways  with  the 
bacillus  of  de  Lisle.  There  is  no  mention 
of  the  results  of  the  Gram  stain.  Inocula- 
tions from  the  placenta  colonies  on  the 
agar-slant,  on  urine-agar,  and  on  blood 
serum,  grew,  though  the  sperm  itself  upon 
these  media  remained  sterile. 

Experiments  were  made  upon  twenty-two 
patients — cases  of  from  ten  months  to  three 
and  a  half  years'  standing.  The  germ  was 
found  in  all  in  whose  spermatic  fluid  sper- 
matozoa could  be  demonstrated.  Aggluti- 
nation was  also  observed  with  the  bacillus, 
and  inoculation  was  made  into  swine  with 
positive  result.  The  authors  make  no  ex- 
travagant claims,  but  express  the  hope  that 
the  field  thus  opened  may  be  exploited  in 
other  parts  of  the  world  by  other  observers. 


BACTERIOLOGY.  33 

Meanwhile,  we  await  the  final  outcome  with 
more  than  usual  interest. 

The  Justus  test  for  syphilis,  first  de- 
scribed by  Dr.  Jacob  Justus,  an  assistant  in 
Schwimmer's  clinic  at  Buda  Pest,  was 
based  upon  the  fact  that  mercury  given 
either  by  subcutaneous  or  intravenous  injec- 
tion, or  by  inunction,  will  cause  a  diminu- 
tion of  the  hemoglobin  of  the  blood. 

Nature  was  said  to  rapidly  replace  this 
loss  in  healthy  subjects,  but  not  in  syphi- 
litics. 

Great  claims  were  made  for  this  test  as 
an  aid  to  the  diagnosis  of  syphilis,  but 
from  many  researches  since  made  it  seems 
to  be  of  no  diagnostic  value.  (Phil.  Med. 
Journal,  May  10,  1902.) 

Note. — In  the  authors'  experience,  mer- 
cury administered  to  a  syphilitic  subject  in- 
creases hemoglobin.) 


PART  V. 


INFECTION. 

The  infection  is  always  conveyed  from 
one  person  to  another  either  by  direct  con- 
tact or  through  the  medium  of  some  instru- 
ment, utensil  or  other  article  upon  which 
the  virus  has  recently  been  deposited;  but 
even  when  the  virus  finds  lodgment  upon 
healthy  integument  or  mucous  membrane, 
infection  does  not  always  occur.  It  is  nec- 
essary for  the  virus  to  enter  the  circulation 
through  some  spot  where  the  skin  or  mu- 
cous membrane  had  been  abraded.  The  so- 
lution of  continuity  may  be  so  slight  as  to 
be  unnoticed;  for  example,  a  tiny  scratch 
or  the  loss  of  the  most  superficial  layer  of 
epithelium,  but  when  the  virus  is  implanted 
upon  an  abraded  surface,  syphilis  will  un- 
doubtedly result. 

The  infectious  material  may  be  derived 
from  the  secretion  of  a  primary  lesion  or 
chancre,  from  mucous  patches,  from  the  se- 

35 


36  SYPHILIS  IN  DENTISTEY. 

cretions  of  Becondary  lesions,  and  from 
syphilitic  blood  during  the  secondary  stage 
of  the  disease. 

The  secretions  from  non-sj^hilitic  lesions 
are  not  infectious^ — that  is,  they  do  not  con- 
vey syphilis,  unless  they  contain  blood ;  for 
example,  the  acne  of  vaccinia,  chancroid  ul- 
cers, etc.  The  physiological  secretions  of 
the  body,  such  as  sweat,  urine  and  milk,  are 
non-contagious,  as  are  also  the  blood  and 
secretions  of  lesions  during  the  tertiary  pe- 
riod. Certain  cases  have  been  reported 
which  are  exceptions  to  the  last  rule. 

By  far  the  most  frequent  mode  of  infec- 
tion is  sexual  intercourse,  but  extra-genital 
chancres  are  very  common.  Munchheimer 
states  that  the  average  is  from  six  to  seven 
per  cent  of  all  cases.  Women  are  more  fre- 
quently the  victims  of  extra-genital  syphilis 
than  men.  Jullien  is  authority  for  the  state- 
ments that  extra-genital  syphilis  occurs  in 
men  in  five  to  six  per  cent  of  all  cases,  and 
in  women  from  twenty-five  to  twenty-six 
per  cent.    Kreftig  finds  a  larger  average. 

Site. — It  is  with  extra-genital  chancres 
only  that  we  have  to  deal  in  this  present 
work,  and  they  form  a  considerable  propor- 


INFECTION.  37 

tion  of  all  primary  sores  which,  are  seen, 
even  in  venereal  clinics,  to  which  the  vic- 
tims turn  for  relic  f  from  tlie  secondary  man- 
ifestations of  the  disease.  In  the  venereal 
clinics  of  Paris,  it  is  found  that  over  five 
per  cent  of  all  chancres  were  extra-genital, 
and  of  the  extra-genital  chancres  over 
sixty-three  per  cent  were  oral,  including 
lips,  throat,  tongue  and  buccal  cavity.  The 
sites  of  extra-genital  chancres  in  the  order 
of  frequency  are  the  lips,  anus,  fingers,  e^-e, 
tongue,  breast,  abdomen,  leg  and  palate.  It 
has  been  stated  that  syphilis  runs  a  more 
severe  course  w^hen  the  chancre  is  extra- 
genital, but  this  is  probably  due  to  the 
fact  that  the  lesions  are  uot  recognized 
until  late  in  their  course.  The  failure  to 
make  a  diagnosis  is  likewise  responsible 
for  the  ''epidemics"  which  not  infrequently 
attack  entire  families,  and  even  communi- 
ties. 

The  chancres  of  the  mouth  are  by  far  the 
most  important,  from  a  dentist's  point  of 
view.  Under  the  heading  are  included  those 
of  the  lips,  tongue,  tonsils,  pillars,  uvula, 
gums  and  the  buccal  cavity.  A  chancre  of 
the  mouth  does  not  differ  in  any  respect 


38  SYPHILIS  IN  DENTISTEY. 

from  a  chancre  found  on  other  mucous 
membranes,  and  persists  from  one  to  five 
weeks. 

Chancres  of  the  mouth  are  acquired  in  a 
variety  of  ways,  but  two  conditions  are 
necessarily  present.  An  abrasion  of  the 
mucous  membrane  of  an  uninfected  in- 
dividual, to  which  the  virus  of  syphilis  is 
applied,  either  directly  or  through  the  me- 
dium of  some  article  on  which  the  virus  ha>s 
been  deposited,  or  fluid  in  which  the  virus 
is  in  suspension.  Perhaps  the  most  fre- 
quent mode  of  transmission  is  through  the 
act  of  kissing,  but  besides  this  mode  of  in- 
fection a  syphilitic  is  a  constant  menace 
to  the  health  of  the  family,  and  to  those 
with  whom  he  has  to  deal  in  the  daily  rou- 
tine of  his  life,  no  matter  how  careful  he 
may  be.  If,  instead  of  constant  watchful- 
ness and  care,  he  is  ignorant  of  his  disease, 
or  careless  of  the  danger  of  infecting  others, 
the  conditions  are  ripe  for  a  rapid  and  far- 
reaching  spread  of  the  malady.  In  his  own 
home  he  uses  the  eating  and  drinking  uten- 
sils, the  same  knives,  forks,  spoons,  in  com- 
mon ^dth  the  other  members  of  the  family, 
and  upon  them  are  lodged  through  the  sa- 


INFECTIOK  39 

liva  the  virus  of  an  orl^l  chancre,  or  much 
more  frequently  the  secretion  of  a  "mucous 
patch."  There  is  no  thought  of  sterili- 
zation, and  the  utensils,  not  being  surgi- 
cally clean,  the  virus  is  not  dislodged,  and 
finds  its  way  to  the  abraded  mucous  mem- 
brane of  the  lips  or  mouth  of  the  unin- 
fected persons  who  use  them. 

The  pipe  habit  is  another  source  of  infec- 
tion, for  many  men  have  a  habit  of  passing 
around  their  pipes  for  every  one  to  have  a 
smoke  from  them.  Cigars  and  cigarettes 
are  passed  from  mouth  to  mouth  "for  a 
light,''  and  the  slight  amount  of  saliva  ad- 
hering is  as  baneful  as  though  there  were 
large  quantities  of  it.  The  cigars  made  in 
sweat  shops  are  likewise  a  source  of  dan- 
ger, as  it  is  the  custom  of  many  cigarmakers 
to  wet  the  wrapper  with  saliva  in  order  to 
make  it  adhere  more  closely. 

Tooth  brushes,  in  some  families,  are  re- 
garded as  common  property  (a  most  filthy 
habit),  and  occasionally  a  servant  tempora- 
rily appropriates  one  of  these  useful  articles 
in  the  absence  of  the  employer,  to  the  eter- 
nal regret  of  one  or  the  other. 

Handkerchiefs  are   more  frequently  ex- 


40  SYPHILIS  IN  DENTISTEY. 

changed  or  loaned,  and  tlie  innocent-looking 
pin  can  create  much  havoc. 

Those  persons  whose  occupation  compels 
them  to  use  in  common  with  others  any  im- 
plement whatsoever  are  in  more  or  less  dan- 
ger, but  where  this  common  work  necessi- 
tates the  use  of  the  mouth,  the  danger  is 
magnified  a  hundredfold.  Among  those 
whose  daily  occupation  thus  exposes  them 
to  syphilitic  contagion  are  glass-blowers, 
who  find  it  impractical  to  use  individual 
pipes ;  assayers,  who  are  accustomed  to  use 
the  blow-pipe  in  common;  conductors' 
whistles,  weavers'  sprinklers,  and  the 
mouthpieces  of  wind  instruments  are  in- 
cluded in  the  list,  while  the  public  tele- 
phone and  speaking-tube  in  business  houses 
are  a  menace  to  the  entire  population. 

There  is  scarcely  a  vocation  which  does 
not  have  its  attendant  possibilities  for  dan- 
ger, when  there  are  associated  together 
many  people,  for  the  habit  of  putting  things 
into  the  mouth  temporarily  is  so  widespread 
and  deep-rooted  that  it  is  next  to  impossible 
to  break  it.  The  upholsterers'  tacks,  the 
shoemakers'  pegs,  the  seamstresses'  pins 
and  needles,  the  pens  and  pencils  of  the 


INTECTION.  41 

clerk  or  scribe,  the  labels  of  druggists,  the 
money  of  everybody,  find  their  way  into  un- 
suspecting mouths. 

Infants  are  frequently  infected  in  the 
mouth  by  nursing  a  syphilitic  wet-nurse, 
and  by  unclean  nursing  bottles.  They,  in 
their  turn,  may  become  syphilitic  and 
spread  contagion.  As  has  been  mentioned, 
the  danger  of  promiscuous  kissing  is  great, 
and  syphilis  of  the  mouth  may  be  acquired 
as  easily  by  kissing  an  unresponsive  infant 
as  by  kissing  an  older  person.  In  addition 
to  this  danger  there  is  added  the  accidental 
infection  that  would  result  from  the  sput- 
tering of  an  infant  in  the  face  of  its  attend- 
ant. 

In  previous  times  there  prevailed  customs 
which  were  at  once  dangerous  and  offensive, 
but  which  have  happily  fallen  into  disuse. 
As  the  result  of  these  antiquated  customs, 
much  infection  was  spread.  Among  these 
customs  may  be  mentioned  breast-drawing 
and  wound-sucking.  Even  to  this  day  it  is 
not  uncommon  in  the  rural  and  frontier 
districts,  where  some  one  is  the  victim  of 
the  bite  of  a  rabid  dog,  for  a  friend  to  at- 
tempt to  draw  the  poison  from  the  wound 


43  SYPHILIS  IF  DENTISTRY. 

by  means  of  suction.  Until  the  advent  of 
tlie  tracheal  catheter,  mouth  to  mouth  insuf- 
flation of  the  asphyxiated  neAV-born  infant 
was  one  of  the  most  frequent  modes  of  re- 
suscitation. 

Under  the  heading;  of  chancres  of  the 
mouth,  too  much  stress  cannot  be  laid  upon 
the  possibility  of  dentists  and  physicians 
infecting  their  patients  from  tongue  depres- 
sors, mouth  gags,  scalpels,  tonsillotomes, 
and  the  various  dental  instruments,  where 
there  is  not  absolutely  perfect  asepsis. 

InfecUom  Through  Fingers  and  Hands. — 
Infection  through  the  fingers  is  by  far  the 
most  frequent  mode  of  inoculation  among 
physicians  and  dentists.  If  cuts,  abrasions 
and  hang-nails  exist,  a  nidus  is  present  for 
the  reception  of  the  virus,  but  if  no  such 
solution  of  continuity  exists^  the  poison  may 
be  carried  to  the  hands,  face,  lips,  or  any 
other  portion  of  the  body,  and  may  be  de- 
posited on  an  abraded  spot,  or,  as  is  not  in- 
frequently the  case,  the  virus  may  be  trans- 
planted on  a  third  and  healthy  person  and 
take  effect. 

Presuming  that  some  of  the  syphilitic  vi- 
rus be  lodged  beneath  the  nails,  the  slight 


IJiTFECTIO^.  43 

irritation  caused  by  scratching  or  pinching 
is  enough  to  give  an  entrance  to  the  infec- 
tious material. 

Laundresses  handling  soiled  clothing  are 
in  constant  danger,  for  the  underclothing, 
containing  the  dried  discharges  of  secreting 
primary,  or,  more  frequently,  secondary, 
eruptions,  are  teeming  with  danger  and  in- 
fection. In  the  same  manner,  and  for  the 
same  reason,  old  clothes  dealers  and  rag 
pickers  are  frequently  infected  through 
their  hands. 

It  is  not  known  how  long  the  virus  of 
syphilis  may  retain  its  potency,  but  it  is 
possible  for  the  infectious  material  to  find 
lodgment  upon  unbroken  skin,  and  there  re- 
main some  days  before  some  accidental 
abrasion  produces  the  necessary  opening, 
through  which  the  long  latent  poison  finds 
its  way  into  the  system,  and  the  result  is  the 
same  as  though  the  infection  had  been  di- 
rect. In  the  same  way  it  is  impossible  to 
state,  though  some  experiments  have  been 
made  in  this  direction,  just  how  long  the 
virus  may  live  when  deposited  on  instru- 
ments or  other  inanimate  articles,  but  that 
it  lives  several  days  is  certain,  and  that  it 


M  SYPHILIS  IN  DENTISTRY. 

withstands  some  antiseptic  treatment  is 
equally  certain. 

Nurses  and  maids  attendant  upon  syph- 
ilitic infants  are  constantly  exposed 
through  handling  the  nursing  bottles,  bath- 
ing and  dressing  the  babe,  caring  for  the 
mother  during  and  after  labor,  and  through 
the  use  of  the  many  articles  necessary  for 
the  care  of  the  infant  and  invalid.  Then, 
again,  babies  have  a  habit  of  clutching  at 
everytliing  within  reach,  and  their  nails  not 
infrequently  produce  slight  wounds.  But 
to  the  dentist  the  imminent  danger  lies  in 
every-day  performance  of  his  professional 
duties.  In  the  dissection  of  a  green  cadaver, 
an  accidental  wound  may  be  inflicted,  or  an 
unnoticed  abrasion  may  exist.  In  operating 
upon  a  patient  where  syphilis  is  unsus- 
pected, an  instrument  may  slip,  and  a  slight 
cut  or  scratch  be  produced,  and  the  mis- 
chief is  done.  Or  the  saliva,  infected  from 
mucous  patches,  may  lodge  in  some  unno- 
ticed scratch,  or,  the  patient  coughing,  the 
saliva  may  fly  in  the  face  or  even  the  eye  of 
the  operator. 

If  a  dentist  should  be  so  unfortunate  as 
to  become  infected  through  the  fingers,  then 


INFECTION.  45 

every  patient  who  comes  to  him  is  in  immi- 
nent danger  of  infection. 

Breast  infection  does  noi.  concern  us  in 
this  treatise,  and  may  be  dismissed  with 
mention  that  it  is  usually  wet-nurses  who 
receive  a  chancre  on  the  nipple,  but  it  must 
be  borne  in  mind  that  it  may  be  the  result 
of  an  examination  by  the  soiled  or  infected 
fingers  of  a  physician.  Infection  on  the 
other  regions  of  the  body  are  accidental, 
and  are  produced  in  a  variety  of  ways,  usu- 
ally being  carried  there  by  soiled  fingers  or 
flying  saliva. 

Syphilis  is  transferred  either  by  mediate 
or  direct  contact ;  there  probably  is  no  such 
thing  as  aerial  transmission  of  the  virus  of 
syphilis.  Chancres  of  the  lips  may  be  the 
result  of  direct  contact,  but  chancres  of 
the  throat  are  always  due  to  the  virus  be- 
ing brought  by  a  carrier,  either  the  finger 
or  instruments,  or  tbe  germ  is  held  in  sus- 
pension in  the  saliva  and  carried  backward. 

"Syphilis  d'embl^e"  is  the  direct  entrance 
of  the  syphilitic  virus  into  the  circulation 
of  a  healthy  person  without  the  production 
of  primary  chancres.  The  possibility  of 
such  a  condition  of  affairs  has  been  affirmed 


46  SYPHILIS  IN  DENTISTRY. 

and  disputed  with  great  vehemence.  While 
such  cases  are  certainly  rare,  it  is  quite  pos- 
sible for  them  to  exist,  and  may  explain  in- 
stances in  which  no  trace  of  chancre  could 
be  found.  The  British  Medical  Journal  re- 
ports two  cases,  which  are  undoubtedly 
cases  in  point.  Dr.  A.  was  operating  upon 
an  emergency  case  for  an  abscess.  The  pa- 
tient had  secondary  syphilis.  The  needle 
was  refractory,  and,  slipping,  punctured  a 
blood  vessel  in  Dr.  A.'s  hand.  His  assist- 
ant. Dr.  B.,  took  up  the  suturing,  when  the 
needle  again  slipped  and  punctured  a  blood 
vessel  in  the  hand  of  Dr.  B.,  in  almost  iden- 
tically the  same  way  as  with  Dr.  A.  No 
chancre  was  produced  in  either  case,  but 
in  twenty-eight  days  both  physicians  broke 
out  with  a  characteristic  secondary  roseola, 
and  both  cases  ran  an  otherwise  typical 
course. 

There  is  no  class  of  persons  who  are  so 
constantly  exposed  to  the  danger  of  syphi- 
litic infection,  or  who,  through  carelessness, 
have  the  possibility  of  exposing  others,  as 
the  dentists. 

The  syphilitic  consults  the  physician  for 
a  sore  throat,  an  ulcer  or  neuralgic  pain, 


INFECTION.  47 

perhaps.  In  the  course  of  the  examination 
many  symptoms  are  brought  out,  and  the 
tell-tale  marks — rash,  eruption  or  ulcers — 
are  discovered,  and  the  diagnosis  easily 
made;  but  when  he  consults  the  dentist 
there  is  little  likelihood  that  any  portion 
of  the  patient's  anatomy,  other  than  the 
mouth  and  face,  can  be  scrutinized  by  him. 
If  a  suggestive  question  is  asked,  the  pa- 
tient is  apt  to  give  misleading  answers  or 
deliberately  falsify.  There  is  an  old  say- 
ing that  "All  syphilitics  are  liars,"  and  no 
one  who  has  had  experience  in  venereal  dis- 
ease doubts  the  truth  of  the  adage.  So  the 
necessity  for  knowledge  by  the  dentist  of 
the  appearance  of  skin  and  mucous  lesions 
in  all  stages  is  apparent  and  imperative, 
and  when  thoroughly  familiar  with  all  the 
varied  manifestations  of  luetic  disease,  it  is 
equally  important  that  the  dentist  know 
how  to  protect  himself  and  others,  and  more 
important  that  he  put  that  knowledge  into 
execution. 


PART  VI. 


THE  INITIAL  LESIONS. 

The  chancre,  or  initial  lesion,  usually  ap- 
pears about  three  weeks  after  inoculation. 
The  site  is  the  point  where  there  existed  a 
solution  of  continuity  of  the  epidermis  at 
the  time  of  the  absorption  of  the  virus.  It 
is  usually  single,  but  is  occasionally  double 
and  even  multiple. 

The  Hunterian  chancre  is  the  typical  ini- 
tial lesion  of  syphilis  found  in  the  male. 
In  the  female  the  typical  form  is  much  less 
common.  According  to  Reed,  the  course  of 
the  chancre  in  women  is  irregular  and  the 
diagnosis  difficult,  sometimes  being  pro- 
nounced and  typical,  at  others  being  small 
and  ephemeral.  This  author,  agreeing  with 
many  others,  divides  chancres  clinically 
into  six  classes: 

(a)  Superficial  or  chancrous  erosion. 

(b)  Scaling  papule. 

49 


50  SYPHILIS  IN  DENTISTEY. 

(c)  Elevated  papule  or  ulcus  elevation. 

(d)  Incrusted  chancre. 

(e)  Indurated  nodules. 

(f)  Diffuse  exulcerated  chancre. 

(a)  Chancrousi  erosion  is  a  non-suppu- 
rating superficial  loss  of  epithelium.  It  is 
found  more  frequently  in  women  than  in 
men.  It  is  always  found  on  a  mucous-  mem- 
brane and  is  often  very  difficult  of  diagnosis 
because  of  its  insignificant  appearance. 

It  begins  as  a  deep  red  spot,  and  losing 
its  epithelium  appears  asi  a  simple  erosion. 
It  is  smooth,  round  or  oval,  and  secretes  a 
thin  serous  fluid.  Pus  only  forms  when  the 
erosion  becomes  the  seat  of  secondary  pyo- 
genic infection.  This  is  the  form  of  chan- 
cre most  frequently  found  in  the  vagina  and 
also  in  the  mouth.  The  induration  is  very 
superficial,  called  by  Fournier  chancre 
parchemine.  The  diagnosis  may  be  difficult 
or  impossible  for  a  few  days,  until  the 
adenitis  in  the  neighboring  lymphatic 
glands  occurs. 

The  duration  of  this  chancre  is  very  brief, 
and  the  physician  may  never  be  consulted, 
and  the  patient  think  nothing  of  it. 

When  it  occurs  in  the  mouth,  it  is  easily 


THE  INITIAL  LESIONS.  51 

mistaken  for  a  stomatitis.  After  this  va- 
riety of  chancre,  constitutional  symptoms 
are  early  mauifested.  When  the  chancre 
disappears,  there  frequently  remains  ai  per- 
sistent red  spot  which  may  continue  for 
months.  When  this  form  occurs  on  the 
labia  in  women,  an  edema  develops  which 
persists  for  a  long  time  after  the  disappear- 
ance of  the  original  lesion. 

(b)  The  scaling  papule  is  a  small,  dull 
red,  slightly  elevated  papule,  which  in  the 
course  of  development  becomes  still  more 
elevated  and  of  a  purplish  hue.  The  edges 
are  distinctly  circumscribed  and  the  lesion 
varies  in  size  from  one-fourth  to  three- 
fourths  of  an  inch  in  diameter.  The  papule 
is  round  or  oval,  hard  to  the  touch.  Through 
irritation  and  diminished  nutrition  the  su- 
perficial epithelium  is  lost  and  a  crust 
forms.  This  is  the  so-called  ecthymatous 
chancre. 

(c)  The  elevated  papule  is  of  a  deep  red 
color,  rounded  or  oval.  It  has  a  flat  or  con- 
cave surface  with  elevated  margins.  It  se- 
cretes a  thin  serous  fluid.  When  through 
lack  of  care,  secondary  infection  takes 
place,  a  very  obstinate  edema  results,  so 


52  SYPHILIS  IN  DENTISTRY. 

great  as  to  frequently  obscure  the  initial 
induration.  This  form  of  chancre  is  of 
much  longer  duration  than  the  two  preced- 
ing varieties,  and  on  disappearing  usually 
leaves  a  scar. 

Sometimes  the  papule  becomes  infected 
and  the  pus,  which  is  of  small  amount,  dries 
with  the  overlying  debris  and  forms  a  crust 
instead  of  a  scale.  When  the  amount  of 
pus  formed  is  greater  it  does  not  dry,  but 
is  retained  beneath  the  central  scale,  and 
we  have  a  pustule  or  syphilitic  herpes.  If 
the  secretion  be  watery  and  retained  be- 
neath the  epidermis  or  crust,  as  noticed  in 
newly  born  infants  suffering  from  heredi- 
tary syphilis,  the  result  is  a  syphilitic  pem- 
phigus. 

When  the  infiltration  occurs  in  a  hair  fol- 
licle (the  induration  being  very  small  is 
difficult  of  demonstration,  but  none  the  less 
real),  infection  occurs  and  pustule  results. 

In  the  course  of  peripheral  development 
of  the  cutaneous  lesions,  two  or  more  pap- 
ules may  coalesce,  each  retaining  its  central 
scale  or  crust,  and  we  have  a  variety  known 
as  syphilitic  psoriasis. 

(d)   The    incrusted    chancre    (a    better 


THE  INITIAL  LESIONS.  53 

name  would  be  diphtheroid)  is  that  form  of 
initial  lesion  which  is  found  on  cutaneous 
surfaces.  It  may  begin  as  an  erosion  or 
nodule,  but,  when  the  overlying  epithelium 
has  been  lost,  the  raw  surface  is  covered  by 
a  creamy  white,  grayish  or  greenish  diph- 
theroid membrane.  It  is  less  common  than 
the  other  forms. 

(e)  The  indurated  nodule  has  as  its 
usual  site  the  junction  of  the  skin  and  mu- 
cous membrane.  It  is  a  sharply  circum- 
scribed plaque,  tubercle  or  nodule,  elevated, 
with  sloping  edges,  and  does  not  secrete  any 
fluid. 

(f)  The  diffuse  exulcerated  chancre  is 
found  in  people  of  the  lower  class  whose 
habits  and  lack  of  personal  cleanliness  pro- 
vide the  environment  suited  to  the  develop- 
ment and  growth  of  all  kinds  of  morbific 
germs.  It  begins  as  an  erosion,  increases 
in  size,  loses  its  epithelium  and  spreads 
over  an  extensive  area.  Its  surface  is  deep 
red  and  uneven.  Its  borders  are  elevated 
and  jagged,  and  surrounded  by  a  densely 
indurated  zone.  It  is  only  slightly  painful. 
This  chancre  secretes  a  thin,  watery  fluid, 
when  uncontaminated.     The  presence  of  a 


54  SYPHILIS  IN  DENTISTRY. 

secondary  pyogenic  infection   changes  the 
secretion,  giving  it  a  purulent  character. 

SYPHILITIC  ULOEES. 

In  the  natural  course  of  retrograde  meta- 
morphosesi,  ulceration  frequently  occurs. 
As  in  the  papule,  degeneration  occurs  in 
the  center,  while  the  peripheral  infiltration 
continues  to  increase  centrifugally. 

The  edges  and  base  of  the  ulcer  are  cov- 
ered with  a  whitish  detritus  resembling 
lard. 

The  edges  of  the  ulcer  are  firm,  sharply 
defined,  somewhat  ragged  and  undermined. 

In  the  center  is  the  usual  crust.  Fluid  is 
secreted  beneath  and  burrows  wider  and 
deeper.  ThiSi  fluid  dries  and  forms  a  sec- 
ond crust  immediately  beneath  the  first,  but 
of  larger  diameter.  Again  fluid  is  secreted 
raising  the  layers  of  crust  above  and  dry- 
ing forms  a  third  and  still  larger  crust  be- 
neath the  other  layers.  And  so  the  process 
continues,  eating  deeper  and  wider  into  the 
subjacent  tissues  and  forming  larger  and 
yet  larger  layers  to  the  central  crust.  When 
the  crust  is  removed  the  typical  undermined 
ulcer  is  observed. 


THE  INITIAL  LESIONS.  55 

After  the  ulcer  has  reached  a  certain  size, 
cicatrization  occurs  at  one  side  from  granu- 
lation  from  healthy  tissue  adjacent.  The 
retardation  of  the  process  at  one  point,  with 
the  steady  growth  in  all  other  directions, 
produces  the  "kidney-shaped"  ulcers  so 
characteristic  of  syphilis. 

SECRETIONS. 

It  may  be  stated  in  a,  general  way  that 
the  secretion  from  all  eroded  chancres, 
when  uncontaminated,  is  serous  or  sero- 
purulent.  The  presence  of  pus  producing 
microbes  as  a  secondary  infection  will  give 
a  purulent  discharge;  and  conversely  when 
the  secretion  from  a  chancre  is  purulent,  it 
has  become  secondarily  infected. 

The  "hemorrhagic"  chancre  is  occasion- 
ally met  with,  and  is  due  to  the  diseased  and 
exposed  condition  of  the  minute  blood  ves- 
sels which  causes  them  to  be  easily  eroded 
or  torn. 

The  amount  of  induration  varies  mark- 
edly in  the  different  forms  of  chancre  and 
in  d liferent  locations.  It  is,  other  things 
being  equal,  apt  to  be  much  greater  on  mu- 
cous membranes  than    on    cutaneous  sur- 


56  SYPHILIS  IN  DENTISTRY. 

faces.  In  occasional  instances  the  indura- 
tion may  be  so  slight  as  to  escape  notice,  if 
the  examination  has  been  hasty,  or  the 
edema  is  extensive  or  when  contaminated 
with  chancroid. 

The  size  of  the  chancre  is  likewise  de- 
pendent upon  the  nature  and  extent  of  the 
solution  of  continuity  at  the  site  of  the  in- 
fection. The  entire  abraded  surface  is 
lil?;ely  to  become  involved  in  the  chancrous 
ulcer. 

Chancre  of  the  lips,  nipple  and  corona 
glandis  are  apt  to  be  extensively  indurated. 

When  a  chancre  occurs  in  the  throat,  it 
is  usually  located  on  one  tonsil.  It  is  often 
not  recognized  because  inflammation  and 
hypertrophy  of  the  tonsils  are  so  common 
and  because  the  earlier  symptoms  differ  in 
no  wise  from  those  of  ordinary  tonsillitis. 
When  the  swelling  and  induration  persist, 
and  the  submaxillary  lymphatic  glands  be- 
come swollen,  and  symptoms  are  unaffected 
by  the  usual  remedies,  chancre  of  the  tonsil 
should  be  suspected.  The  size  and  variety 
of  the  chancre  will  vary  in  this  locality 
upon  the  same  conditions  which  modify  it 


THE  INITIAL  LESIONS.  57 

els€wlier(i — the  presence  of  previous  inflam- 
matory changes  and  pyogenic  bacteria. 

CICATRIX. 

Chancres,  when  small  and  but  slightly  in- 
durated, with  free  lymphatic  supply,  disap- 
pear sooner  than  other  forms  and  leave 
"ham-colored"  spots,  which  fade  to  a  cop- 
pery hue;  later  they  fade  completely,  leav- 
ing no  trace,  while  stubborn,  densely  infil- 
trated, deep  ulcers  leave  permanent  and 
characteristic  scars.  In  some  cases  scars 
result  from  the  treatment  of  chancres. 

INOCULABILITY. 

Chancres  are  non-autoinoculable,  and 
this  is  taken  as  an  absolute  diagnostic  dif- 
ference between  them  and  the  ulcers  of 
chancroid,  from  which  it  is  important  to 
differentiate  them.  When  a  chancre  be- 
comes secondarily  involved  by  pus  cocci,  it  is 
very  possible  to  infect  the  neighboring  sur- 
face with  the  pyogenic  organisms,  but  the 
resultant  lesions  are  not  similar  to  the  pri- 
mary ulcers,  and  the  pus  from  them  will  not 
produce  syphilis  in  another  individual. 

If  the  secondary  infection  is  chancroid, 
there    may  be  as  many    secondary    chan- 


58  SYPHILIS  IN  DENTISTEY. 

croidal  ulcers  result  from  autoinoculation 
as  tliough.  cliancroid  existed  alone.  Neither 
are  these  secondary  ulcers  of  the  character 
of  hard  chancres. 

A  case  is  reported,  however,  of  autoinocu- 
lation with  blood  from  the  side  of  the  initial 
lesion  before  the  appearance  of  the  ulcer. 
Wallace  cites  a  case  of  autoinoculability, 
when  in  the  eruptive  stage,  while  Fournier 
states  that  two  per  cent  of  autoinoculations 
are  successful.  Lydston  thinks  that  under 
conditions  of  filth,  heat  and  moisture,  a 
germ  infection  of  a  chancre  might  be  pro- 
duced, resulting  in  an  ulcer  of  a  chancroid- 
al character. 

PATHOLOGY. 

The  changes  that  occur  in  the  formation 
of  a  hard  chancre  are  inflammatory  in  char- 
acter, modified  to  a  certain  extent  by  the 
presence  of  the  specific  virus  of  syphilis. 
This  virus  is  as  yet  unidentified  (Vide  Part 
IV).  The  same  changes,  under  slightly  dif- 
ferent environment,  are  to  be  found  in  all 
the  secondary  syphilides. 

When  the  poison  of  syphilis  is  deposited 
on  an  abrasion  in  otherwise  healthy  skin, 


THE  INITIAL  LESIONS.  59 

a  cycle  of  phenomena  at  once  begins.  The 
first  manifestation  of  this  cycle  is  the  infil- 
tration of  the  tissue  at  the  site  of  infection 
with  small  round  cells,  exactly  as  in  any 
inflammation.  With  these  small  round  cells 
are  also  to  be  seen  large  round  or  oval  and 
polyhedral  cells,  filling  up  the  interstices 
between  the  meshes  of  the  network  of  blood 
capillaries.  At  first  the  blood  vessels  are 
not  involved,  but  shortly  by  extension  they 
are  included  in  the  inflammatory  process. 
New  connective  tissue  of  a  perishable  or 
embryonic  type  is  formed.  This  tendency  to 
connective  tissue  formation  is  also  observed 
in  the  tertiary  stage  in  lesions  of  the  nerv- 
ous system  due  to  syphilis. 

The  lymphatic  channels  are  soon  involved 
in  the  inflammatory  process  and  the  virus, 
which  is  either  a  microbe,  or,  as  Otis  sug- 
gests, a  microbe-bearing  cell,  is  borne  along 
these  vessels  to  the  nearest  lymphatic 
glands,  where  it  is  deposited,  and  the  same 
process  of  inflammation  is  repeated  and  the 
glands  become  swollen  and  indurated. 
"First  intuition  virus"  has  traveled  from 
the  site  of  infection. 

This  is  the  period  of  first  incubation. 


60  SYPHILIS  IN  DENTISTEY. 

MICROSOOPIOAL. 

A  section  under  the  microscope  reveals  a 
mass  of  semi-necrotic,  round,  multi-nuclear 
cells  containing  granules,  with  large  poly- 
hedral and  round  cells  here  and  there.  The 
lumen  of  the  blood-vessels  is  distinctly  les- 
sened, and  the  walls  thickened  by  the  pres- 
ence of  an  inflammatory  zone.  There  is  no 
fluid  to  be  found  in  this  inflammatory  zone. 
The  thickness  of  the  vessel  walls  precludes 
that,  and  accounts  for  the  hardness  of  indu- 
ration. Around  this  mass  of  round-celled 
infiltration  is  a  zone  of  edema,  which  acts 
as  a  barrier,  preventing  the  spread  of  virus 
into  the  adjacent  healthy  tissues. 

A  section  through  one  of  the  swollen 
lymphatics  shows  a  similar  condition,  a 
simple  inflammation  plus  these, large  multi- 
nuclear  polyhedral  cells. 

Prom  the  germ-laden  lymphatic  glands 
the  virusi  is  carried  by  way  of  the  larger 
lymphatic  vessels  and  emptied  into  the  re- 
ceptaculum  chyli,  thence  intO'  the  general 
circulation,  and  the  disease,  which  up  to 
this  time  is  apparently  local,  becomes  sys- 
temic. 


THE  IXITIAL  LESIONS.  61 

According  to  Besiadecki,  there  is  first  an 
accumulation  of  lymphocytes  or  white 
blood  corpuscles,  at  the  site  of  inoculation. 
These  normal  cells  become  modified  by  the 
presence  of  syphilitic  virus.  Otis  claims 
that  there  is  present  a  very  minute  de- 
graded cell,  bearing  the  infectious  material, 
which  acts  as  the  carrier  of  contagion. 

These  modified  cells  bearing  the  germs  of 
infection  become  larger  and  granular  and 
possess  many  nuclei.  Their  amoeboid  move- 
ments are  increased  and  their  powers  of 
proliferation  multiplied. 

When  these  cells  come  in  contact  with 
healthy  normal  leucocytes,  as  in  non-in- 
fected individuals,  these  cells  have  the 
power  to  produce  changes  in  the  leucocytes 
(proliferation)  and  they  undergo  changes 
in  themselves  (Lydston). 

The  theory  that  the  degraded  cells  may  be 
the  nuclei  of  disintegrated  leucocytes  is 
plausible.  In  their  travels  they  meet  with 
other  leucocytes  by  whose  phagocytic  ac- 
tion they  are  absorbed.  In  this  manner  the 
size  of  the  leucocytes  is  increased,  but  be- 
cause of  the  morbific  action  of  the  included 
germs  the  life  of  the  cells  is  imperiled. 


PART  VII. 


SECONDARY  MANIFESTATIONS. 

Secondary  mauifestations  of  syphilis  be- 
gin to  appear  from  four  to  eight  weeks  after 
the  initial  lesion.  They  are  ushered  in  by 
slight  fever,  headache  and  malaise.  The 
appearance  of  the  rash  is  the  confirmation 
of  our  diagnosis  of  syphilis.  This  period 
from  the  appearance  of  the  chancre  till  the 
appearance  of  the  earliest  secondary  or  con- 
stitutional symptoms  is  called  the  period  of 
second  incubation. 

It  may  be  stated  that  the  causes  at  work 
in  the  iiroduction  of  the  chancre  prevail  in 
the  production  of  the  secondary  eruption 
and  in  the  formation  of  the  gummatous  de- 
posits of  the  third  stage.  The  exciting  fac- 
tor is  the  presence  of  the  syphilitic  poison, 
whatever  its  nature,  because  of  it  there  are 
deposited  in  certain  places  cells  of  the  same 
kind  as  were  found  in  the  chancre,  which  re- 
semble round  cells  of  inflammation,  but 
63 


64  SYPHILIS  IN  DENTISTEY. 

have  the  giant  cells  with  them,  and  do  not 
readily  lend  themselves,  to  reparative  proc- 
ess. 

SECONDARY  ERUPTION. 

The  consideration  of  the  secondary  erup- 
tion is  of  the  utmost  importance,  not  only 
to  the  patient,  but  to  the  physician  and  den- 
tist as  well.  In  many  cases  the  chancre  has 
been  inconspicuous,  and  has  been  entirely 
overlooked  by  the  patient.  It  is  rather  a 
difficult  matter  for  a  man  to  think  a  trivial 
little  sore,  which  is  not  painful  and  does 
not  inconvenience  him,  and  which  to  his 
eyes  looks  like  a  dozen  other  little  sores  he 
has  had,  is  the  precursor  to  years  of  af- 
fliction by  eruption  and  rashes,  pains  and 
SAvellings.  The  appearance  of  the  second- 
ary rash  is  the  first  thing  that  attracts  the 
patient's  attention,  and  for  which  he  con- 
sults the  physician. 

With  the  absence  of  a  history  of  infec- 
tion, as  will  usually  be  the  case,  when  the 
chancre  is  extra-genital,  with  the  denial  by 
the  patient  of  the  existence  of  a  chancre, 
and  the  lack  of  a  tell-tale  scar  to  throw  a 
ray  of  light  on  an  obscure  case,  a  diagnosis 


^1 


PAPULOPUSTALAR  -  SECONDARY     ERUPTION 

(  Takt-n  from  Snundcrs    Ilatid  Atlas) 


SECONDARY  MANIFESTATIONS.       65 

must  be  made  from  secondarj^  eruptions 
aloue.  When  there  are  only  the  c-utaneous 
syphilidesi  to  tell  the  stor}',  the  diagnosis 
may  be  difficult,  but  when  in  addition  to  the 
skin  eruptions  vre  find  nnirous  patches  or 
plaques  muqueuscs,  the  diagnosis  is  abso- 
lutely certain. 

All  secondary  eruptions  are  able  to  com- 
municate the  disease  to  others,  and  the 
plaques  muqueuses  are  especially  prolific  of 
danger,  and  it  is  through  them,  far  more 
frequently  than  through  the  chancre,  that 
not  only  venereal  but  extra-genital  syphilis 
is  disseminated. 

If  syphilis  were  characterized  by  but  one 
form  of  eruption  it  would  be  an  easy  matter 
to  identify  it,  but  there  are  many  skin  dis- 
eases, each  with  its  own  peculiar  rash,  and 
syphilis,  which  is  an  imitative  disease,  may 
counterfeit  in  a  general  way  any  and  all  of 
them. 

The  necessity  of  recognizing  syphilis  in 
all  of  its  forms,  and  of  differentiating  it 
from  the  many  diseases  w^hich  it  may  simu- 
late is  obvious. 

There  are  several  points  which  all  syphi- 
lides  have  in  common,  and  which,  taken  to- 


66  SYPHILIS  IN  DENTISTRY. 

gether,  may  be  considered  as  pathognomonic 
of  syphilis. 

1.  Syphilitic  rashes  or  syphilides,  are  su- 
perficial. They  are  situated  in  the  papillary 
layer  or  the  corium  of  the  skin  and  extend 
only  superficially.  There  is  no  tendency,  as 
in  tertiary  lesions,  to  extend  into  the  deep 
tissues,  and  very  little  tendency  to  increase 
peripherally,  though  twoi  or  more  closely 
situated  lesions  may  coalesce. 

2.  It  is  only  the  epidermis  overlying  the 
syphilides  that  is  destroyed,  and  it  is  re- 
placed by  new  epithelium. 

3.  If  the  lesion  is  not  contaminated  by 
pus  cocci,  there  is  no  tendency  to  ulcerate. 

4.  The  epidermis  is  replaced  and  does  not 
leave  a  scar. 

5.  There  is,  however,  a  deposit  of  pig- 
ment where  the  syphilide  occurred,  which 
is  of  a  characteristic  ham  or  copper  color. 
This  spot  may  disappear  very  shortly,  leav- 
ing no  trace.  It  may  appear  immediately  or 
its  appearance  may  be  delayed  a  few  days. 

G.  Syphilitic  rashes  may  or  may  not  itch. 

7.  They  are  symmetrical  on  both  sides  of 
tlie  body. 

8.  The  roseola  disappears  on  pressure. 


SECONDAEY  MANIFESTATIONS.       G7 

LOCATION. 

The  rashes  of  syphilis  have  a  predilection 
for  certain  portions  of  the  body  which  they 
attack  first.  If  there  is  only  a  slight  rash 
it  may  be  confined  to  the  preferred  loca- 
tion, but  in  severe  forms  the  other  portions 
are  attacked  in  a  definite  order. 

The  lower  two-thirds  of  the  chest  is  most 
often  the  seat  of  secondary  eruptions,  and 
following  in  order  of  frequency  are: 
The  abdomen. 
Front  of  legs  and  thighs. 
Flexor  surfaces  of  arms  and  forearms. 
Back  of  neck. 
Scalp,  beginning  at  forehead  (corona 

veneris) . 
Posterior  surface  of  thighs  and  nates. 
Posterior  surface  of  legs. 
Back. 

Posterior  surface  of  arms. 

Face — the  face  is,  fortunately  for  the 

victim,  least  often  attacked,  and  is 

free,  except  in  very  severe  forms  of 

eruptions. 

Syphilis  may  attack  the  palms    of    the 


68  SYPHILIS  IN  DENTISTRY. 

hands  and  the  soles  of  the  feet  with  a  dry, 
scaly  eruption  which  greatly  resembles 
psoriasis,  and  is  called  syphilitic  psoriasis. 
But  this  is  of  later  date  than  the  general 
rash. 

TIME. 

After  a  variable  period,  usually  from 
forty  to  forty-flve  daysi  subsequent  to  the 
chancre,  there  appears  a  general  erythema 
much  more  profuse  on  the  anterior  aspect 
of  the  trunk  and  flexor  surfaces  of  the 
limbs;  but  in  severe  cases  may  include  the 
whole  body.  This  is  known  as  the  syphilitic 
roseola  or  roseola  syphilitica.  This  erythe- 
ma is  in  the  form  of  sharply  defined,  dull 
rose  or  bluish  red  blotches,  which  vary  in 
size  from  one-fourth  tO'  five-eighths  of  an 
inch  in  diameter.  The  spots  do  not  scale, 
never  itch,  and  disappear  without  leaving 
a  trace,  but  when  long  continued  leave  be- 
hind a  ham  or  copper  colored  pigmentation. 

The  rash  may  last  only  a  few  hours,  in 
which  case  it  may  not  be  observed,  or  it 
may  last  for  two  or  three  months. 

The  roseola  may  be  accompanied,  but  is 


SECONDAEY  MANIFESTATIONS.       69 

usually  followed,  by  an  eruption  of  pap- 
ules, which  are  scattered  over  the  trunk 
and  limbs,  but  are  especially  noticed  on 
the  forehead  in  the  border  of  the  hair. 
When  thickly  studded  they  form  a  peculiar 
band  which  is  termed  the  corona  veneris  or 
venereal  crown. 

The  secondary  rash  is  not  to  be  con- 
founded with  the  secondary  eruption, 
known  as  cutaneous  syph Hides  or  syphilo- 
dermata.  The  two  may,  and  frequently  do, 
co-exist.  The  rash  disappears  on  pressure; 
the  eruptions  do  not. 

It  is  not  to  be  supposed  that  one  of  these 
spots  continues  throughout  the  entire  pe- 
riod of  secondary  eruption.  The  blotches 
as  they  disappear  leave  pigmented  areas 
and  new  blotches  and  papules  form  in  their 
stead,  so  that  several  forms  of  the  syphilides 
may  be  found  at  one  time,  and  their  places 
be  taken  later  by  other  forms  of  eruptions. 

All  forms  of  syphilodermata,  with  the 
exception  of  the  roseola,  were  originally 
papules  or  nodules,  and  it  is  only  location, 
irritation  and  contamination  with  pyogenic 
infection  that  produces  the  different  varie- 
ties given  by  most    authorities,  but    some 


70  SYPHILIS  IN  DENTISTEY. 

-WTitersi  content  themselves  with  dividing  all 
syphilides  into  two  classes: 

Squamous  and  Papular, 

A  vast  amount  might  be  written  on  the 
subject  of  pathology,  but  a  practical  work, 
such  as  this  is  intended  to  be,  has  little  need 
of  a  chapter  on  microscopy  and  pathology, 
though  a  general  statement  of  pathological 
conditions  is  not  amiss. 

There  is  a  slight  inflammatory  condition 
in  the  deep  layers  of  the  skin-papillary  layer 
and  corium.  The  circulation  is  interfered 
with  and  the  hemoglobin  of  the  blood  is 
broken  up  and  its  pigment  deposited  in  the 
skin. 

Owing  to  the  inflammation  and  deficient 
supply  of  nourishment,  as  well  as  the  ten- 
sion on  the  overlying  epidermis,  it  dies  and 
is  desquamated,  new  epidermis  taking  its 
place. 

Under  the  finger  the  papule  feels  hard, 
like  shot  under  the  skin,  or  like  a  "pimple." 
It  increases  in  diameter,  but  the  central 
portion,  which  is  the  oldest,  disappears  and 
leaves  a  "dent,"  which  is  covered  with  a 
scale.    This  scale  is  quite  characteristic  and 


SECONDAEY  MANIFESTATIONS.       71 

should  be  borne  in  mind.  The  outer  por- 
tion is  red  and  shiny  from  the  tightly 
drawn  skin. 

A  rather  unusual,  but  none  the  less  im- 
portant, form  of  secondary  eruption  is 
knoAvn  as  sypMlitic  lichen,  and  also  as 
syphilitic  acne,  from  its  resemblance  to 
acne,  though  in  it  the  sebaceous  follicles  are 
not  inflamed,  and  the  "black  heads"  do  not 
break  down  with  pustules. 

It  is  found  usually  on  the  lower  part  of 
abdomen,  and  anterior  surfaces  of  the 
thighs.  It  is  much  more  abundant  than 
the  acne,  which  it  counterfeits,  and,  like  all 
syphilides,  does  not  itch,  and  has  a  brown- 
ish discoloration. 

A  still  rarer  form  of  secondary  rash  is 
known  as  the  pigmentary  syphilide.  It  is 
found  only  in  women  and  upon  the  neck. 
It  is  a  brownish  or  blackish  discoloration, 
which  causes  the  skin  to  look  as  if  it  was 
in  need  of  a  vigorous  application  of  soap 
and  water. 

PRODEOMES. 

Accompanying,  or  in  some  instances  pre- 
ceding, the  roseola,  as  more  or  less  constant 


72  SYPHILIS  IN  DENTISTEY. 

symptoms,  are  what  are  frequently  called 
the  syphilitic  prodromata;  they  are  auor- 
exia,  nausea,  headache,  neuralgic  pains, 
nervous  irritability,  general  malaise,  and 
not  infrequently  a  rise  in  temperature. 

Syphilitic  fever  is  extremely  variable  in 
character.  There  may  be  a  constant  but 
slight  pyrexia,  the  temperature  rising  to 
101  degrees,  or  it  may  assume  a  remittent 
or  even  an  intermittent  form,  the  tempera- 
ture rising  as  high  as  104  or  105  degrees, 
and  dropping  five  or  six  degrees.  Such 
cases  are  easily  confounded  with  malaria, 
and  the  diagnosis  is  only  cleared  by  the 
therapeutic  test. 

Kicord  and  Otis  are  of  the  opinion  that 
the  fever  is  not  dependent  upon  syphilitic 
infection,  and  is  merely  a  coincidence;  but 
the  generally  accepted  view  is  that  the  fever 
is  directly  caused  by  and  dependent  upon 
the  presence  of  the  syphilitic  germs  or  their 
toxines  within  the  system;  that  the  minor- 
ity of  cases  in  which  the  pyrexia  is  not  man- 
ifest are  explained  on  the  grounds  of  idio- 
syncrasy, or  more  perfect  elimination 
through  the  various  channels  of  excretion. 


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MUCOUS  PATCHES. 

Uudoiibtedly  the  most  important  of  all 
the  syphilitic  lesions,  especially  from  a  den- 
tal standpoint,  are  the  mucons  patches,  or 
plaques  muqneuses,  which  are  observed 
upon  the  mucous  membranes,  quasi-mucous 
membranes,  and  moist  portions  of  the  skm, 
during  the  secondary  stage  of  the  disease. 

These  plaques  are  in  structure,  and  mode 
of  development,  very  similar  to  the  papules 
found  on  cutaneous  surfaces,  but  conditions 
of  heat  and  moisture,  which  are  ever  pres- 
ent, together  with  the  irritation  due  to  fric- 
tion or  foreign  substances,  modify  their  ap- 
pearance and  growth. 

A  most  important  feature  of  the  plaque 
muqueuse  is  the  secretiou  of  a  glairy  fluid 
which  is  highly  contagious,  and  which  is 
the  most  usual  cause  of  syphilitic  infection 
If  the  secretion  of  a  mucous  patch  be  placed 

75 


76  SYPHILIS  IN  DENTISTRY. 

upon  an  abraded  spot  in  the  integument  of 
a  healthy  person,  a  chancre  will  undoubt- 
edly result,  but  autoinfection  from  the  se- 
cretion of  a  mucous  patch  will  not  produce 
a  new  chancre  (although  another  mucous 
patch  might  result) . 

Mucous  patches!  are  not  painful,  and 
when  few  and  small  give  rise  to  no  incon- 
venience, and  are  consequently  often  ig- 
nored and  their  dangerous  character  not 
appreciated ;  in  fact,  in  some  cases  they  are 
so  insignificant  and  harmless  in  appearance 
that  a  diagnosis  is  well  nigh  impossible. 

In  the  mouth  the  first  manifestation  of 
the  secondary  stage  of  syphilitic  infection  is 
the  appearance  of  a  general  dull  red  erythe- 
ma involving  the  entire  fauces.  The  ery- 
thema soon  fades,  leaving  symmetrically 
disposed  erythematousi  spotsi  on  both  sides 
of  the  palate,  the  walls  of  the  pharynx,  the 
pillars  of  the  fauces  and  the  sides  of  the 
tongue. 

These  patches  are  sharply  defined,  slight- 
ly elevated,  round  or  oval,  and  vary  in  size 
from  three  toi  five  millimeters  in  diameter. 
At  first  they  are  deep  red  in  color,  but  later 
they  become  a  grayish  white.    They  secrete 


MUCOUS  PATCHES.  77 

a  viscid  fluid  which,  as  before  stated,  is 
highly  contagious. 

Under  the  fingers  they  feel  hard  to  the 
touch,  the  borders  are  elevated  and  the  cen- 
tral portion  depressed. 

When  mucous  patches  are  subject  to  irri- 
tation, they  have  a  tendency  to  break  down 
and  ulcerate,  especially  is  this  true  of  mu- 
cous patches  situated  on  the  tonsils.  As 
a  result  of  this  low  type  of  ulceration,  the 
glands  in  the  neighborhood  become  swollen 
so  that  when  plaques  muqueuses  are  found 
in  the  mouth  and  throat  we  may  expect  an 
involvement  of  the  occipital  and  sterno-mas- 
toid  glands. 

Mucous  patches,  when  situated  on  this 
moist  skin,  or  quasi-mucous  membranes, 
change  their  character  somewhat,  and  be- 
come considerably  hypertrophied,  and  have 
a  tendency  to  multiply,  forming  fungous  or 
warty  new  growths.  Tbese  patches,  unless 
kept  most  scrupulously  clean,  secrete  a  foul 
smelling  discharge.  They  are  termed  tuber- 
cles or  condylomata. 

The  mouth  is  especially  subject  to  mu- 
cous patches,  because  of  the  constant  pres- 


78  SYPHILIS  IN  DENTISTEY. 

ence  of  irritation  from  decayed  teeth,  hot 
foods,  alcoholic  beverages,  tobacco^  and  pipe 
stems. 

Tobacco  users  are  especially  liable  to  this 
secondary  manifestation  of  disease.  The 
action  of  the  pipe  stem  upon  one  part  of  the 
lip,  long  continued,  as  with  heavy  pipe- 
smokers;,  supplies  the  requisite  irritation, 
and  a  mucous  patch  appears  upon  the  smok- 
er's lip.  It  is  very  slightly  elevated,  cov- 
ered with  a  whitish  film,  and  is  very  persist- 
ent and  annoying.  Such  milky  patches  are 
termed  plaques  opalines.  However,  a  non- 
specific sore  closely  resembling  a  plaque 
opaline  may  appear  on  the  lips  of  a  heavy 
smoker  who  is  not  syphilitic.  This  is  due 
simply  to  the  irritant  action  of  the  smoke 
and  pipe  stem.  It  is  also  very  stubborn  to 
treatment,  and  unless  the  source  of  irrita- 
tion is  removed  will  remain  indefinitely,  in 
spite  of  all  treatment.  It  is  not  elevated 
and  not  indurated. 

There  are  similar  non-specific  patches  to 
be  found  occasionally  upon  the  tongue  and 
cheeks,  which  are  termed  leukoplasia  or 
leukoplakia. 


MUCOUS  PATCHES.  79 

SECONDAEY      SYPHILIS      OP      THE 
NOSE. 

^Mucous  patches  are  sometimes  found  in 
the  nares.  When  such  is  the  case  they  are 
situated  either  at  the  outer  angle  or  ante- 
rior mucous  surface  near  its  junction  with 
the  cuticle.  They  are  small,  round,  or  oval, 
and  slightly  raised — in  fact,  presenting  no 
difference  in  appearance  from  plaques  mu- 
queuses  found  in  the  mouth.  They  occur  in 
point  of  time  with  other  mucous  patches 
and  cutaneous  syphilides.  They  are  accom- 
panied by  a  profuse  mucopurulent  dis- 
charge which  interferes  with  the  circulation 
of  air  through  the  nose. 

Mucous  patches  may  become  secondarily 
infected,  the  same  as  any  other  lesion,  by 
pus  germs,  and  when  so  complicated  ulcers 
will  result.  These  have  the  characteristic 
undermined  appearance  of  syphilitic  ulcers 
elsewhere.  They  ai'e  situated  on  a  hard 
base  and  have  overhanging,  jagged  though 
sharply  defined  edges. 

The  secondary  manifestations  of  syphilis 
upon  the  pharynx  and  tonsils  begins  by  a 
dull    red    erythema    and    fading,    leaves 


80  SYPHILIS  IN  DENTISTKY. 

patclies  scattered  over  tlie  tonsils  and  walls 
of  the  pharynx.  The  patches  are  similar  to 
mucous  patches  seen  on  the  lips;  they  are 
round  or  oval  in  size,  symmetrically  dis- 
posed upon  both  sides,  elevated  and  sharply 
defined  and  covered  with  a  grayish  deposit. 
Because  of  the  lymphatic  structure  of  the 
tonsils  and  their  tendency  to  pus  infections, 
and  the  ease  with  which  foreign  substances 
may  be  lodged  within  their  crypts,  we  find 
the  mucous  patches  in  the  tonsils  espe- 
cially prone  to  ulceration.  When  ulceration 
does  occur,  it  sometimes  extends  quite 
deeply  into  the  tonsils,  otherwise  it  is  the 
same  as  the  ulcerating  patches  in  other  por- 
tions of  the  mouth. 

OCULAR  SYPHILIS. 
The  eyes  are  victims  of  the  secondary 
manifestations  of  the  disease,  an  iritis  being 
frequently  observed,  but  the  diagnosis  be- 
longs to  the  oculist,  rather  than  to  the  den- 
tist or  general  practitioner. 

OSSEOUS  SYMPTOMS. 
Late  in  the  secondary  stage  of  syphilis 
there  is  an  inflammation  of  the  periosteum 
of  the  bones;   it  is  exceedingly  painful,  es- 


MUCOUS  PATCHES.  81 

pecially  at  night.  It  is  not  to  be  confounded 
with  nodes  and  gummata  of  tertiary  syphi- 
lis. Occasionally  we  find  swelling  of  the 
joints,  with  an  accumulation  of  fluid,  as  a 
secondary  syphilitic  manifestation,  but  such 
cases  are  infrequent  and  not  diagnostic. 

ALOPECIA. 

About  the  time  of  the  appearance  of  the 
secondary  rash  and  sore  throat,  the  hair 
may  begin  to  fall.  As  a  rule  there  is  an  ab- 
sence of  rash  upon  the  scalp,  though  occa- 
sional papules  may  be  found  scattered  over 
the  hairy  portion  of  the  head,  and  the 
trouble  usually  begins  as  a  dryness  of  the 
scalp,  which  may  go  no  further,  but  the  irri- 
tation may  become  severe  and  crusts  may 
even  form;   this,  however,  is  unusual. 

The  hair  becomes  greatly  thinned,  but  in 
some  places  the  scalp  becomes  entirely  bald, 
giving  the  head  a  peculiar  appearance,  joc- 
ularly called  a  "polka-dot  hair  cut." 

The  trouble  is  caused  by  the  disease  af- 
fecting the  roots  of  the  hairs  themselves, 
and  when  the  disease  is  brought  under  con- 
trol, there  is  nothing  to  prevent  new  hair 
from  coming;  in. 


83  SYPHILIS  IN  DENTISTRY. 

The  beard  and  eye-brows  are  subject  to 
the  same  process,  and  the  hairs  of  the  eye- 
brows are  not  infrequently  all  shed,  leav- 
ing the  victim  with  a  peculiarly  bald  ap- 
pearance of  the  faee. 

As  has  been  previously  stated,  the  sec- 
ondary rash  rarely  affects  the  face,  and  does 
so  only  in  severe  cases.  Almost  the  only 
manifestations  on  the  face  in  secondary 
syphilis  is  the  affection  of  the  hairy  parts 
— the  brows  and  beard. 


,jJi&iiiS&^ 'i.,        ..^  .^tiiSPd.'iiiSh 


TERTIARY     DESTRUCTION 

(Taketi  from  Saunders   Hand  Atlas] 


PART   IX. 


TERTIAKY  SYPHILIS. 

There  can  be  laid  down  no  hard  and  fast 
rule  with  regard  to  the  tertiary  period  of 
syphilis.  The  secondary  and  tertiary  stages 
may  be  so  merged  the  one  into  the  other 
that  lesions  of  the  two  periods  may  co-exist. 
On  the  other  hand,  the  appearance  of  the 
tertiary  manifestations  may  be  delayed  for 
years,  and  the  patient  rest  secure  under  the 
delusion  that  he  is  free  at  last  from  the 
dreaded  ravages  of  the  disease,  only  to  be 
rudely  awakened  to  the  realization  that 
there  is  no  security  from  that  nemesis. 

Many  authorities  consider  that  tertiary 
symptoms,  properly  speaking,  are  not  syphi- 
litic, in  the  true  sense  of  the  word,  but  are 
merely  sequelae,  just  as  nephritis  and  mid- 
dle ear  disease  are  sequels  of  scarlatina, 
and  not  in  any  sense  the  disease  itself. 

Tertiary  manifestations  of  syphilis  differ 
from  those  of  the  true  secondary  stage  in 
85 


86  SYPHILIS  IN  DENTIS'TEY. 

being  non-contagious  and  in  their  tendency 
to  eat  deeply  into  the  tissues,  as  well  as  to 
extend  laterally  and  to'  ulcerate.  As  has 
been  stated,  previously,  there  is  no  tendency 
on  the  part  of  the  papules  of  the  secondary 
stage  to  ulcerate. 

Experiments  upon  tertiary  lesions  have 
proved  tha.t  they  do  not  communicate  syphi- 
lis when  inoculated  upon  healthy  individ- 
uals, but  a  fact  which  must  be  borne  in  mind 
and  never  lost  sight  of  is  that  secondary 
contagious  lesions  may  exist  at  the  same 
time  with  non-contagious  tertiary  lesions 
and  communicate  the  disease  to  others. 

Many  syphilographers  divide  tertiary 
manifestations  into  two  classes — early  and 
late  tertiaries.  While  the  classification  is 
unsatisfactory  and  misleading,  it  will  be 
adopted  in  this  treatise  in  lieu  of  a  better 
one.  The  early  tertiaries  appear  directly 
after  secondary  cutaneous  eruptions  and 
are  themselves  cutaneousi.  They  differ  from 
the  secondary  syphilides  in  their  tendency 
to  ulcerate.  In  fact,  the  evolution  of  a  rash 
is  so  gTadual  as  to  defy  the  elect.  The  sec- 
ondary and  a  number  of  the  tertiary  cuta- 
neous lesions  are  frequently  coexistent.    As 


TEETIAEY  SYPHILIS.  87 

the  cutaneous  lesions  seem  to  merge  the 
one  into  the  other,  they  will  be  considered 
together.  It  may  be  stated,  however,  that 
the  syphilitic  impetigo  and  ecthyma  are  the 
connecting  link  between  secondary  and  ter- 
tiary. Syphilitic  rupia  are  a  little  later 
and  may  be  considered  as  true  tertiary  skin 
lesions. 

Following  the  cutaneous  tertiaries  in 
point  of  time,  are  the  tubercular  syphilides. 
The  tuberculous  syphilide  is  really  a  super- 
ficial gumma — found  in  the  corium  of  the 
skin.  In  all  respects  it  resembles  the  true 
gumma,  which  is  the  latest  of  all  syphilitic 
manifestations. 

The  gumma  is  the  type  of  tertiary  lesion, 
just  as  the  mucous  patch  is  the  type  of  sec- 
ondary manifestation.  However,  gummata 
are  not  confined  to  the  skin  and  mucous 
membranes,  as  were  the  earlier  lesions,  but 
may  and  do  attack  every  organ  in  the  body 
having  a  special  predilection  for  the  liver, 
lungs,  kidneys  and  brain. 

A  gumma  is  an  accumulation  of  cells  of 
a  peculiar  tyi^e,  closely  resembling  the 
round  cells  of  inflammation,  but  differing 
from  them  in  having  no  tendency  to  a  repar- 


88  SYPHILIS  IN  DENTISTEY. 

ative  process,  but  a  great  tendency  toward 
the  destruction  of  the  surrounding  tissues, 
breaking  down  into  ulcers  with  pus  forma- 
tion, and  leaving  behind  unsightly  scars 
and  disfiguring  bands  of  cicatricial  tissue. 

The  gumma  proper  is  found  in  subcuta- 
neous tissues  and  deeper  structures.  When 
occurring  in  the  Sikin  the  term  superficial 
gumma  or  tuberculous  syphilide  has  been 
applied.  No  organ  of  the  body  is  exempt 
from  the  ravages  of  syphilis  in  its  late  or 
tertiary  stage,  though  certain  organs  such 
as  the  liver,  lungs,  kidneys  and  brain  are 
more  frequently  the  seat  of  the  gummata. 

The  presence  of  gummata  in  the  deep- 
seated  organs  may  be  recognized  by  signsi 
and  symptoms,  if  large  and  multiple.  On 
the  other  hand,  they  may  be  so  small  and 
inconsiderable  in  numbers,  or  so  situated  as 
to  interfere  not  at  all  with  the  functions 
of  the  organs  in  which  they  are  seated,  and 
thus  give  rise  to  no  symptoms  and  their 
presence  never  be  suspected  during  life. 

The  presence  of  gummata  in  the  deeper 
organs  does  not  concern  us,  and  will  not 
be  considered  in  this  work. 


TERTTAEY  SYPHILIS.  89 

GUMMATA  OF  THE  SKIN. 

Properly  speaking,  gummata  do  not  at- 
tack the  skin,  but  an  accumulation  of  gum- 
matous cells,  when  found  in  the  skin,  is 
termed  a  "superficial  giimma"  or  "tubercu- 
lar syphilide."  Such  accumulations  are 
small,  ranging  in  size  from  a  fine  shot  to  a 
pea.  They  frequently  become  infected  and 
break  down  into  ulcers,  closely  resembling 
the  infected  syphilides  of  the  secondary 
stage,  but  differing  from  them  in  that  their 
secretions  are  non-contagious.  They  may 
be  found  during  the  late  secondary  stage 
along  with  secondary  manifestations. 

GUMMATA  OF  MUCOUS  MEMBRANES. 

Gummata  ai'e  frequently  found  on  mu- 
cous membranes  and  when  so  situated  the 
destructive  process  is  rapid  and  the  tend- 
ency to  repair  is  slight. 

The  gumma  is  at  first  small,  but  increases 
in  size  from  that  of  a  fine  shot  to  a  small 
pea  and  softens.  Finally  it  becomes  yel- 
lowish and  ruptures,  breaking  down  into 
an  ulcer.  Such  ulcers  may  be  superficial 
or  deep.     Tliey  have  overhanging,  jagged 


90  SYPHILIS  IN  DENTISTKY. 

edges,  are  sharply  defined  and  secrete  pus 
with  an  exceedingly  offensive  odor.  When 
the  pus  is  removed,  the  bottom  of  the  ulcer 
is  seen  to  be  made  up  of  fungoid  growths. 
The  tendency  of  such  ulcers  is  to  spread  lat- 
erally and  to  eat  deeply  into  the  neighbor- 
ing structures,  sometimes  wreaking  havoc 
as  they  progress. 

Phagedena  rarely  attacks  primary  chan- 
cres, or  even  the  secondary  lesions  of  syphi- 
lis, but  gummata  are  not  so  exempt,  but  on 
the  other  hand  are  prone  to  become  phage- 
denic. 

While  gummata  and  their  ulcerative  proc- 
esses are  pathologically  the  same  wherever 
located,  their  clinical  effects  vary  with  their 
site.  They  become  of  special  importance 
and  interest  to  the  dental  surgeon  when  sit- 
uated in  the  mouth  or  nose. 

GUMMATA  OP  THE  THROAT. 

When  occurring  in  the  throat,  gummata 
are  small  and  multiple.  They  are  found 
frequently  on  the  soft  palate  and  the  pil- 
lars of  the  fauces.  In  these  locations  they 
break  down  and  form  ulcers  of  the  superfi- 
cial variety.     They  last  from  two  to  three. 


TERTIARY     DESTRUCTION 

(TaA-ett  from  Saunders'  Hand  Atlas) 


TEETIAEY  SYPHILIS.  91 

weeks  and  constitute  one  of  the  causes  of 
syphilitic  sore  throat. 

GUMMATA  OF  THE  HAED  PALATE. 

Owing  to  the  predilection  of  the  disease 
for  cartilage  and  bone,  the  hard  palate  is 
frequently  attacked.  A  gumma  forms  on 
the  roof  of  the  mouth  in  front  of  the  soft 
palate,  and  this  breaks  down  into  a  deep 
ulcer.  The  periosteum  of  the  palate  bones 
becomes  involved  beneath  the  ulcer  and  a 
perforation  results.  According  to  Ingals, 
this  can  occur  in  ten  to  fifteen  days.  The 
ulcer  in  time  heals,  but  a  round  hole  is 
left  connecting  the  oral  cavity  with  the 
nasal  cavity.  This  round  perforation  is  ab- 
solutely diagnostic  of  tertiary  syphilis.  It 
frequently  calls  for  a  surgical  interference. 

Occasionally  perforation  results  from  the 
destructive  process  of  an  ulcer  which  was 
not  preceded  by  a  gumma. 

TEETIARY  SYPHILIS  OF  THE  NOSE. 

While  syphilis  may  attack  the  nose  in 
the  primary  and  secondary  stages,  these  are 
rather  unusual  occurrences,  but  in  the  ter- 
tiary stage  the  nasal  mucous  membranes 


92  SYPHILIS  IN  DENTISTEY. 

are  frequently  attacked.  The  severity  of 
the  attack  varies  greatly.  In  some  eases 
there  is  a  slight  obstruction  of  the  nasal 
passages  due  to  the  thickened  mucous  mem- 
brane, in  others  there  may  be  present  con- 
dylomata, and  in  exaggerated  cases  there 
may  be  gummata  which  ulcerate,  involving 
mucous  membrane,  cartilage  and  bone  in 
their  destructive  processes. 

Necrosis  of  the  bone  and  cartilage  is  due 
to  periostitis  and  perichondritis — an  exten- 
sion of  the  inflammation  from  the  ulcer  to 
the  periosteum  and  perichondrium. 

The  destruction  of  the  nasal  bones  is  a 
late  tertiary  manifestation,  usually  occur- 
ring several  years  subsequent  to  the  pri- 
mary chancre,  but  in  occasional  malignant 
cases  it  may  occur  within  a  year. 

Accompanying  the  necrosis  there  is  ob- 
served a  mucopurulent  rhinitis.  The  dis- 
charge has  a  peculiar  stench,  which  is  not 
entirely  removed  even  by  the  most  rigid 
antiseptic  and  thorough  and  frequent  ablu- 
tions. 

The  destruction  of  the  nasal  bones  with 
the  consequent  flattening  of  the  bridge  of 


TEETIAEY  SYPHILIS.  93 

the  nose  when  not  due  to  fracture  is  due  to 
syphilis.  No  other  disease  so  completely  de- 
stroys the  bones  of  the  nose  and  leaves  its 
name  so  indelibly  written  on  the  features 
of  its  victims. 


PART   X. 


INTERSTITIAL  GINGIVITIS. 

Interstitial  gingivitis  or  pyorrhea  alveo- 
laris,  variously  known  as  Riggs'  disease, 
Fauchard's  disease,  and  by  some  other 
names,  remains  to  this  day  a  bete  noire  to 
dentists.  Tliis  is  mainly  due  to  the  fact 
that  they  cannot  cure  it  and  the  best  meth- 
ods at  their  command  to-day  lie  in  pros- 
thetic dentistry.  Without  desiring  to  pose 
as  carping  critics,  the  method  is  bad  and  is 
surely  a  petitio  in  forma  jmuperis  to  him 
wiio  is  able  to  observe  and  reason. 

In  this  trouble,  as  well  as  in  others,  it 
is  necessary  to  determine  the  cause  and  then 
properly  treat  it  or  eliminate  it,  and  it  is 
to  this  very  question  of  cause  that  the  pres- 
ent is  written.  He  who  has  had  opportunity 
to  observe  a  number  of  cases,  of  syphilis  has 
not  failed  to  observe  that  a  peculiar  mani- 
festation shows  itself  at  first  in  connection 
with  the  lower  canine  teeth.  This  will  then 
95 


96  SYPHILIS  m  DENTISTRY. 

spread  to  the  incisors  and  at  times  to  the 
first  bicuspids.  If  the  examination  be 
pushed  a  little  farther  the  gum  covering 
the  tooth  root  will  be  found  to  be  reddened 
and  angry  looking,  and  if  it  be  pressed  some 
pain  is  elicited  and  pus  is  found  to  exude 
apparently  from  the  alveolar  process.  This 
it  is  which  has  led  dentists  to  regard  it  as 
a  purulent  destruction  of  the  alveolus,  be- 
cause drawing  the  tooth  did  not  reveal  any 
marked  alteration  of  the  bone  during  the 
earlier  period  of  the  disease,  but  rather  a 
marked  collection  of  pus  in  the  alveolar  cav- 
ity. 

As  a  natural  consequence  it  was  found 
much  easier  to  clean  out  the  offending 
teeth,  and  patients  were  advised  to  have 
all  the  affected  teeth  drawn  and  replaced  by 
a  bridge,  which  is  certainly  more  profitable 
to  the  dentist,  while  more  inconvenient  to 
the  patient.  As  an  example  of  prosthetic  den- 
tistry, it  is  certainly  a  success,  but  as  a 
means  of  cure  it  is  anything  but  such.  Care- 
fully examining  every  case  of  syphilis  com- 
ing under  observation  and  noting  the  facil- 
ity with  which  pus  could  be  made  to  exude 
from  the  alveoli  by  simple  j^ressure  on  the 


INTEESTITIAL  GINGIVITIS.  97 

gums  led  to  a  further  search,  which  led  to 
the  discovery  of  the  same  coudition  in  indi- 
viduals who  were  suffering  from  gout  and 
other  so-called  dyscrasise.  The  inevitable 
conclusion  would  be  that  these  general  con- 
ditions were  the  cause  of  the  local  symp- 
toms observed.  In  other  words,  the  trouble 
of  the  alveolar  process  was  nothing  but  a 
local  indication  of  some  general  condition 
which  existed  and  which  should  be  cor- 
rected in  addition  to  the  elimination  of  the 
local  trouble  which  manifested  itself. 

It  was  then  that  a  more  careful  examina- 
tion of  the  teeth  of  syphilitics  was  entered 
into  and  the  result  was  the  finding  of  a  com- 
paratively large  number  of  cases  of  pyor- 
rhea alveolaris.  Upon  request  a  number  of 
dentists  submitted  cases  to  me.  These  were 
very  carefully  questioned,  and  about  two- 
thirds  gave  a  history  of  syphilis.  A  suffl- 
cient  number  existed  to  classify  them  as 
cases  of  syphilis  ignoree,  or  as  old  cases  of 
tertiai'}'  sj'ljhilis  in  which  this  was  the  only 
bone  symptom  to  be  observed.  However, 
this  may  be,  the  subsequent  treatment 
showed  that  the  etiology  had  been  correctly 


98  SYPHILIS  IN  DENTISTEY. 

established  and,  as  a  natural  consequence, 
the  treatment  was  successful. 

In  view  of  the  fact  that  the  few  observa- 
tions made  have  shown  a  greater  or  less  in- 
terdependence between  syphilis  and  pyor- 
rhea alveolaris,  would  it  not  be  a  useful 
matter  for  every  one  to  pay  more  attention 
to  the  dental  trouble?  To  say  the  least,  is 
it  not  a  curious  coincidence  that  Riggs' 
disease  should  be  observed  in  so  many 
cases  of  secondary  syphilis  as  well  as  the 
late  form  of  this  period?  It  must  also  be 
remarked  that  pyorrhea  alveolaris  occurs 
as  a  parasyphilitic  phenomenon.  When  we 
take  into  consideration  that  the  teeth  are 
observed  to  be  all  sound  before  syphilitic 
infection,  and  that  after  the  disease  has 
manifested  itself  it  shows  its  presence ;  and, 
further,  when  systemic  as  well  as  local 
treatment  directed  to  the  syphilis  causes 
both  to  disappear  we  are  certainly  justified 
in  concluding  that  lues  is  a  factor  in  the 
production  of  Eiggs'  disease.  We  are  un- 
fortunately prevented  from  making  experi- 
mental inoculations,  or  the  matter  could 
be  definitely  settled  by  inoculating  the  pus 
of  the  pyorrhea  in  a  subject  who  had  never 


INTERSTITIAL  GINGIVITIS.  99 

contracted  syphilis.  Of  course,  there  would 
remain  the  possibility  of  producing  nothing 
but  a  purulent  infection  and  not  a  chancre. 
The  object  of  this  chapter  has  been  to  call 
the  attention  of  syphilologists  and  dentists 
to  the  point  announced  in  the  title,  and 
observation  will,  beyond  all  doubt,  lead  to  a 
number  of  valuable  ideas  and  the  elabora- 
tion of  methods,  not  only  for  the  treatment, 
but  for  the  prevention  as  well,  of  this  most 
distressing  disease  of  the  teeth.  It  is  for 
conservatism  that  we  are  ever  striving,  not 
for  radical  destruction,  and  there  is  no 
doubt  whatever  that  a  little  care  and  study 
will  enable  us  to  save  many  valuable  teeth 
which  are  being  daily  sacrificed  on  account 
of  a  confessed  inability  to  successfully 
treat  the  condition  known  as  pyorrhea 
alveolaris. 


PART   XI. 


DIFFERENTIAL  DIAGNOSIS. 

In  the  diagnosis  of  syphilis,  the  forego- 
ing features  are  of  the  greatest  value  col- 
lectively. In  every  case  the  whole  situation 
must  be  reviewed  and  determined  by  care- 
ful questioning  and  observation.  Learn, 
also,  the  general  conditions  of  the  suspect 
and  whether  the  other  tissues  have  been 
affected. 

It  is  unnecessary  to  enter  minutely  into 
the  details  of  the  differential  diagnosis  be- 
tween syphilis  and  the  more  frequent  con- 
ditions which  may  be  met  with  and  mis- 
taken for  this  gTave  disease. 

If  attention  be  paid  to  the  prominent 
features  as  described,  especially  when 
assisted  by  a  knowledge  of  the  history  of 
the  ease  and  a  careful  search  for  co-existing 
symptoms  or  signs  of  syphilis  or  traces  of 
their  previous  existence,  the  dentist  will  not 
often  be  left  in  doubt. 

lOI 


102 


SYPHILIS  m  DENTISTRY. 


If  any  uncertainty  exist,  it  is  far  better 
for  all  concerned  if  the  patient  have  the 
benefit  of  a  trial  of  specific  remedies  before 
resorting  to  operative  procedures. 

The  cardinal  signs  and  symptoms  are 
arranged  in  parallel  columns  for  easy  com- 
parison : — 


SECONDARY     SYPHIL- 
ITIC RHINITIS. 

Sudden  onset. 

Course  long  and  obsti- 
nate. 

Coincident  condylomata 
and  mucous  patches. 

Syphilitic  history. 


CHRONIC  RHINITIS. 

Onset  more  gradual. 

More  amenable  to  treat- 
ment. 

No  condylomata  or  mu- 
cous patches. 

No  syphilitic  history. 


TERTIARY  SYPHILITIC 
RHINITIS. 

Later  in  life. 

No  rice  bodies. 

Predilection  for  bone 
equal  to  that  for  carti- 
lage. 


LUPUS. 

Earlier  age  (except  her- 
editary syphilis). 

Peculiar  reddish  papules 
and  rice  line  bodies. 

Predilection  for  cartilage 
and  not  bone. 


TERTIARY  SYPHILITIC 
RHINITIS. 

Odor  characteristic. 

Necrosis  of  bone  and  car- 
tilage. 

Classic  symptoms  of  early 
syphilis,  scars,  etc. 

History. 


ATROPHIC      RHINITIS. 

Not  so  offensive. 

No    necrosed    bone    and 

cartilage. 
No  such  history  or  signs 

of  syphilis,  scars,  etc. 


DIFFERENTIAL  DIAGNOSIS. 


103 


SYPHILITIC      SORE 
THROAT. 

History  of  infection. 
Inflammation  slight. 

Little  swelling. 

Slight  rise  in  tempera- 
ture. 

Little  pain. 

No  difficulty  in  swallow- 
ing and  opening  mouth. 

Symmetrically  disposed. 


ACUTE  TONSILITIS. 

No  specific  history. 
Inflammation  much 

greater. 
Much  swelling. 
Temperature  high. 

Pain  very  severe. 
Difllculty       in      opening 
mouth  and  swallowing. 
Usually  unilateral. 


SYPHILITIC     SORE 
THROAT. 

Syphilitic  history. 

May  be  in  children,  if  so 

hereditary. 
No  emaciation. 
Little  fever  and  pain. 
Hoarseness,  no  dysphagia 

or  aphonia. 
Ulcer     sharply       defined 

with  edges. 

Undermined. 

Situated  on  a  thickened 
base  with  surrounding 
area  of  redness. 

Duration  brief. 


TUBERCULAR     SORE 
THROAT. 


Tubercular      hist. 

sj''philitic  history. 
Usually  adults. 


No 


Rapid  emaciation. 

High  fever,  much  pain. 

Aphonia,  dysphagia,  dys- 
pnea. 

Ulcer  superficial,  indefi- 
nite edges,  not  under- 
mined. 

Grayish  perforated  ap- 
pearance. 

Progresses  rapidly. 


Anaemic    mucous    mem- 
brane. 


SYPHILITIC      ULCER 
OF  TONSIL. 

Swelling  and   induration 

slight. 
Usually  bilateral. 
Syphilitic  history. 
Ulcer  has  indurated  base. 


CANCER  OF  TONSIL. 

Much  swelling  and  indu- 
ration. 
Usually  unilateral. 
No  history  of  syphilis. 
No  indurated  base. 


104 


SYPHILIS  IN  DENTISTRY. 


Edges    sharply     defined, 

undermined. 
May     be     superficial     or 

deep. 
Little  or  no  pain. 

No  cachexia. 
Discharge  not  so  offen- 
sive. 


Edges    not    undermined, 

grayish. 
Profuse  granulations. 

Pain  very   severe  before 

and  after  ulceration. 
Cachexia  marked. 
Fetid  discharge. 


MUCOUS  PATCHES. 

Duration  short. 
Round  or  oval,  smaller. 

Seldom  on  cheek. 

Often  on  tip,  margin  and 
under  surface  of 
tongue. 

Patches  thinner. 

Glands  involved. 

No  carcinomatous  ten- 
dency. 

Patches  grayish  or  red. 


XEUCOPLASIA   BUCCA- 

LIS. 
May  last  for  years. 
Form       irregular,      may 

grow  quite  large. 
Frequently  on  cheek. 
Never  found  in  these  lo- 
cations. 

Patches  thickened. 
If  involved,  only  later. 
Tendency  to  develop  into 

carcinoma. 
Patches  very  white. 


PART  XI 


ILLUSTRATIVE  CASES. 

Illustrations  of  any  kind  often  serve  to 
impress  clearly  and  permanently  upon  the 
mind,  facts  which  might  othei'wise  be  not 
thoroughly  appreciated,  and  consequently 
easily  forgotten. 

We,  therefore,  have  deemed  it  advisable 
to  conclude  our  remarks  upon  syphilis  and 
its  varied  manifestations  as  pertaining  or 
relating  to  the  dental  profession,  by  a 
series  of  cases  taken  from  our  own  experi- 
ence, and  from  the  practices  of  other  physi- 
cians, which  will  fully  demonstrate  many 
of  the  points  we  have  endeavored  tO'  point 
out  in  the  foregoing  pages. 

CASE  1.  Dentist,  American,  aged 
thirty-two,  jflrst  noticed  a  small  ulceration 
on  the  lower  lip  which  rapidly  enlarged. 
He  applied  dusting  powders  and  ointments, 
which  seemed  to  have  little  effect;  finally 
the  condition  became  so  annoying  that  he 
107 


108  SYPHILIS  IK  DENTISTEY. 

consulted  a,  physician,  who  referred  him 
to  the  authors  for  diagnosis.  He  absolutely 
denied  having  kissed  anyone  except  his  wife, 
but  on  questioning  him,  found  he  was  in 
the  habit  of  holding  one  instrument  in  his 
mouth  while  working  with  another.  Acting 
upon  suggestion,  he  produced  a  list  of 
the  patientsi  he  had  treated  during  the 
previous  six  weeks.  On  going  over  them>, 
he  remembered  one  woman  who  had  white 
patches  on  her  tongue.  Upon  reexamining 
her  mouth  he  found  several  large  ulcera- 
tions on  her  tongue,  and  both  tonsils  were 
involved.  She  also  had  enlarged  cervical 
glands  and  beginning  syphilitic  alopecia. 
The  woman  in  this  case,  as  in  many  others, 
did  not  know  she  had  syphilis.  Four  weeks 
later  the  secondary  eruption  appeared  on 
the  dentists  body,  and  treatment  was 
begun. 

CASE  2.  On  October  8th,  1896,  there 
appeared  in  the  office  a  young  man  26  years 
of  age,  who  came  for  consultation  in  regard 
to  a  peculiar  eruption  which  had  caused 
him  much  annoyance,  not  because  of  any 
irritation  at  the  site  of  the  lesions,  but 
rather  because  of  consequent  disfiguration. 


ILLUSTEATIVE  CASES.  109 

He  is  an  American;  has  been  practicing 
dentistry  for  four  years ;  he  is  married  and 
the  father  of  two  children.  Had  never 
had  a  skin  eruption  before;  there  was  no 
history  of  gonorrhea  or  chancre.  The  pres- 
ent eruption  occurred  about  two  weeks  pre- 
viously in  the  form  of  small  red  blotches, 
erythematous  in  appearance.  It  was  accom- 
panied with  violent  headaches  and  a  feeling 
of  general  debility.  Since  then,  small  pap- 
ules appeared  on  the  chest,  back,  face  and 
extremities,  and  also  on  the  scalp.  There 
was  a  general  indolent  adenitis  present. 
The  patient  could  not  remember  any  par- 
ticular lesion  preceding  these  except  a  very 
stubborn  sore  ( small )  upon  the  index  finger 
of  the  right  hand  near  the  matrix  of  the 
nail.  This  he  explained  by  saying  he  had 
accidentally  scratched  himself  in  this  place 
with  a  dental  instrument  while  working 
upon  the  teeth  of  one  of  his  patients.  The 
epitrochlear  and  axillary  glands  upon  the 
right  side  were  much  enlarged  and  some- 
what tender  to  the  touch.  There  was  no 
doubt  this  dentist  had  synhilis  and  that  his 
infection  was  either  from  a  scratch  with 
one  of  his  instruments  previously  used  upon 


110  SYPHILIS  IN  DENTISTRY. 

a  patient  with  syphilis,  or  infection  of  the 
wound  from  the  patient  upon  whose  teeth 
he  was  working  at  the  time.  The  latter 
theory  he  scouted,  saying  that  she  was  a 
very  estimable  woman,  a,  social  leader,  and 
one  in  whom  it  would  be  almost  a  crime 
to  suspect  the  presence  of  the  disease. 

CASE  3.  A  man,  aged  22  years,  came 
to  the  clinic  of  the  Post-Graduate  School 
in  January.  1895,  with  a  large  papular 
syphilide.  The  glands  in  the  neck  were 
very  much  enlarged  and  there  wasi  a  sore  on 
the  lower  lip,  at  the  internal  border  of  the 
mucous  membrane  at  the  right  side.  He 
had  not  been  exposed  to  any  infection  that 
he  knew  of.  He  had  been  under  the  care 
of  the  dentist  for  some  weeks  and  remem- 
bered sustaining  a  slight  injury  during  the 
course  of  dental  work. 

CASE  4.  A  man,  aged  47,  an  express 
driver,  in  September,  1897,  first  noticed  a 
small,  hard  lump  on  the  edge  of  the  upper 
lip,  on  the  left  side,  near  the  margin  of 
the  mucous  membrane,  which  became  hard 
and  wasi  accompanied  by  considerable  swell- 
ing. The  patient  remembered  that  a  few 
weeks  before  he  had  been  under  the  care 


ILLUSTRATIVE  CASES.  Ill 

of  a  dentist  and  while  there  had  received 
an  injury  at  this  point.  The  glands  gener- 
ally were  enlarged,  maciilo  sjphila  present. 
CASE  5.  Last  year  a  physician  from 
one  of  the  Western  States  consulted  the 
authors  in  regard  to  complete  loss  of  hair 
from  the  face,  head,  axilla,  pubes,  and,  in 
fact,  he  was  a  typical  case  of  alopecia  uni- 
versalis; made  a  very  careful  examination 
of  the  skin,  which  was  negative;  examined 
the  glands  and  found  them  slightly  en- 
larged. The  glands  in  the  neck  were  more 
enlarged  than  in  the  groin.  The  glands  in 
the  epitrochlear  region  were  also  enlarged. 
The  mouth  and  throat  showed  no  syphilitic 
conditions;  asked  him  if  he  had  a  chancre, 
and  he  denied  it  point  blank;  examined  his 
rectum  and  found  two  small  condylomata 
and  several  mucous  patches.  During  the  ex- 
amination he  stated  that  he  had  had  an  in- 
fection on  his  second  finger,  second  joint, 
about  four  months  before,  which  he  had  a 
good  deal  of  trouble  in  healing  up;  exam- 
ined the  finger  and  found  a  scar  about  the 
size  of  a  dime.  He  said  that  the  condition  on 
the  fingerwas  produced  by  opening  his  office 
door  and  catching  it  on  a  thumb  bolt  under 


112  SYPHILIS  IE"  DENTISTEY. 

tlie  handle  of  the  door.  He  said  at  the  time 
he  was  treating  two  cases  of  chancre  of  the 
cervix.  Diagnosing  the  case  as  one  of  syph- 
ilis, and  the  seat  of  the  initial  lesion  the 
second  finger,  he  was  put  on  syphilitic  treat- 
ment, and  before  he  had  left  the  city  there 
were  several  mucous  patches  in  the  nose 
and  mouth;  corresponded  with  him  since 
and  he  reports  that  the  alopecia  has  been 
cured,  and  he  is  recovering  from  the  des- 
pondency which  followed  when  he  found  he 
had  contracted  syphilis. 

CASE  6.  An  interesting  case  is  that 
communicated  by  Dr.  Baum.  In  August, 
1897,  a  patient,  25  years  of  age,  was  admit- 
ted to  Ward  18  of  the  Cook  County  Hos- 
pital with  a  sore  situated  upon  the  right 
hand.  The  examination  showed  a  raised 
sore  mth  a  markedly  depressed  center, 
situated  on  an  indurated  base,  the  hand 
somewhat  swollen  and  edematous.  The  epi- 
trochlear  and  axillary  glands  were  much 
enlarged  and  painful.  The  other  glands 
were  somewhat  enlarged.  The  patient  gave 
the  following  history.  About  six  weeks  be- 
fore his  admittance  to  the  hospital,  he  was 
in  an  altercation  with  a  friend,  ending  in 


ILLUSTKATIVE  CASES.  113 

a  fight,  in  course  of  which  he  struck  his 
friend  in  the  mouth  Avith  his  right  hand, 
producing  an  injury  on  the  site  of  the  pres- 
ent lesion.  lie  states  that  at  that  time  his 
friend  was  suffering  from  a  sore  on  the  lips. 
Two  weeks  after  admission  the  patient  de- 
veloped the  erythemato-papular  macular 
syphilide. 

CASE  7.  In  June  1898,  Mr.  K.,  a  syph- 
ilitic patient,  brought  into  the  authors' 
office  the  young  lady  to  whom  he  was  en- 
gaged. She  had  been  in  the  care  of  a  throat 
specialist  two  months  previously  for  an  ul- 
cerated condition  of  both  tonsils.  The  con- 
dition returned,  and,  on  examination, 
mucous  patches  were  found  on  both  tonsils, 
side  of  the  mouth,  uvula  and  tongue.  On 
further  examination  found  the  disappearing 
secondary  eruption,  and  the  initial  lesion, 
which  was  located  in  the  angle  of  the 
mouth,  showing  more  on  the  inner  than  on 
the  outer  surface.  The  sublingual  glands 
on  the  same  side  were  enlarged  to  the  size 
of  a  hazel  nut.  The  man  confessed  that  he 
had  not  followed  the  authors'  instructions 
not  to  kiss  an^^one,  but  had,  on  the  contrary, 


114  SYPHILIS  IN  DENTISTEY. 

been  in  the  liabit  of  kissing  tliis  girl,  and 
hence  had  infected  her. 

CASE  8.  A  baby  four  months  old  was 
brought  to  the  clinic  by  its  sister.  On  ex- 
amination of  the  baby,  found  a  secondary 
eruption,  enlarged  lingual  gland,  and  a  true 
chancre  on  the  left  side  of  the  lower  lip; 
sent  for  mother.  On  examination  of 
her,  found  a  fast  disappearing  ulceration 
under  the  left  nipple.  The  history  she  gave 
was  as  follows :  The  flow  of  milk  was  very 
slow  and  her  husband  had  used  his  mouth 
on  her  breast  to,  as  she  expressed  it,  hurry 
up  the  milk,  and  the  sore  appeared  a  month 
afterwards.  So  here  we  have  a  father  in- 
fecting a  mother's  breast  and  her  breast, 
in  turn,  infecting  the  baby.  During  one  of 
the  examinations,  the  sister  leaned  over 
and  kissed  the  child  to  quiet  it;  explained 
the  danger  to  her  of  infection,  but  four 
months  afterwards  she  presented  a  chancre 
on  her  upper  lip. 

CASE  9.  Miss  A.,  perfectly  healthy 
otherwise,  was  suffering  from  tonsilitis. 
She  consulted  a  physician  who  advised  her 
to  have  the  tonsillar  abscess  lanced,  which 
was  done,  and  immediate:  recovery  occurred. 


ILLUSTRATIVE  CASES.  115 

Four  weeks  later  she  was  again  troubled 
with  the  left  tonsil,  the  one  previously 
affected.  This  time  she  consulted  Dr.  W., 
who  found  her  to  be  suffering  from  chancre 
of  the  tonsil.  Careful  study  of  the  case  re- 
vealed no  other  source  of  infection  than  the 
scalpel,  with  which  the  tonsil  had  been 
lanced.  Upon  inquiry  it  was  learned  that 
the  physician  had  last  used  the  scalpel  upon 
a  syphilitic  patient,  more  than  a  week  prev- 
iously, and  it  had  been  sterilized  (?) 
previous  to  using  it  upon  Miss  A. 


PART   Xlll. 


MEDICO  LEGAL  ASPECTS. 

The  medico  legal  aspects  of  this  subject 
are  as  highly  important  as  any  part  of  it 
and  demand  the  most  serious  consideration 
at  the  hands  of  the  dental  profession.  As 
we  have  remarked  earlier  in  the  book,  ig- 
norance of  the  law  constitutes  no  bar  to 
becoming  a  defendant  in  an  action  at  law, 
and  it,  therefore,  behooves  every  practicing 
dentist  to  become  thoroughly  familiar  with 
this  phase  of  the  subject. 

Wherever  the  virus  of  syphilis  is  im- 
planted in  the  slightest  solution  of  con- 
tinuity of  epidermis  of  an  individual  who  is 
not  already  syphilitic,  there  will  be  pro- 
duced a  syphilitic  sore. 

As  the  virus  is  so  easily  communicated, 
especially  by  the  mucous  patch,  and  not  only 
directly,  but  by  indirect  means,  as  saliva, 
blood,  spoons  and  instruments  and  vessels 
of  all  kinds,  it  is  not  surprising  that  we  so 
"7 


118  SYPHILIS  IN  DENTISTEY. 

frequently  see  cases  where  the  primary 
chancre  was  obtained  while  in  the  dentist's 
chair. 

While  it  is  indisputable  that  the  moral 
responsibility  of  the  dentist  in  such  cases 
is  very  great,  it  is  our  opinion  that  the  inno- 
cent victim  has  a  most  excellent  claim  at 
law  for  mulcting  in  very  heavy  damages, 
the  dentist  who  infects  him,  no  matter  how 
innocently  and  unintentionally  it  may  have 
been  done.  It,  therefore,  behooves  us  all 
to  meet  the  question  fairly  and  frankly, 
and,  recognizing  our  moral  and  legal  re- 
sponsibility, to  take  such  measures  that  we 
may  not  at  some  time  pose  as  defendants 
in  courts  of  law. 

Every  one  with  whom  the  syphilitic  asso- 
ciates is  in  danger  of  being  infected  and 
not  to  SO'  inform  a  patient  suffering  with 
syphilis  is  to  aid  in  its  dissemination.  Do 
not  reason  and  common  sense  dictate  that 
it  is  better  to  confine  syphilis,  if  possible, 
in  the  narrowest  limits,  even  at  the  expense 
of  disquietude  of  the  patient  and  possible 
loss  of  the  patient's  patronage,  than  to 
stand  idly  by,  when  judicious  explanation 


MEDICO  LEGAL  ASPECTS.  119 

might  place  the  whole  matter  in  another 
light? 

The  assumption  is  reasonable  that  if  a 
better  understanding  existed  as  to  the 
danger  incident  to  syphilis,  innocent  per- 
sons would  be  less  frequently  exposed  there- 
to in  the  wanton  fashion  now  prevalent, 
and  to  which  we  called  attention  in  the  pre- 
ceding chapters. 

It  is  only  just  that  men  and  women  who 
give  or  propagate  syphilis  should  be  pun- 
ished and  we  feel  quite  certain  that  any 
court  or  jury  in  the  land  would  impose  a 
heavy  penalty  on  a  dentist  who  caused, 
either  directly  or  indirectly,  a  patient  to 
acquire  such  a  horrible  affliction  while  help- 
less in  his  care. 

It  is  the  duty  of  every  physician  to  pub- 
lish as  far  as  it  lies  in  his  power,  the 
knowledge  that  may  save  life. 

Physicians  in  the  exercise  of  their  pro- 
fession are  constantly  working  against 
their  best  interests  by  teaching  the  preven- 
tion of  disease.  They  so  fulfill  their  mis- 
sion. Dentists  must  do  the  same  or  pay  the 
penalty  an  outraged  public  will  certainly 
exact. 


120  SYPHILIS  IN  DENTISTEY. 

Sterilization  of  instruments  in  this  day 
of  advanced  knowledge  is  a  foregone  con- 
clusion and  that  every  dentist  sterilizes  his 
instruments  we  have  not  the  slightest 
doubt,  but  the  question  arises,  is  ordinary 
sterilization  sufficient  for  such  a  virulent 
poison?  The  answer  is  a  most  emphatic 
negative. 

It  is  customary  among  dentists  to  ster- 
ilize instruments  with  95  per  cent  carbolic, 
neutralize  the  acid  with  alcohol,  wash  with 
water  and  wipe.  For  ordinarv  cases  this 
is  sufficient,  perhaps,  but  not  for  syphilis. 

Every  practicing  dentist  should  have  an 
extra  set  of  instruments  for  such  cases.  Be- 
fore and  after  using  they  should  be  boiled 
in  water  to  which  is  added  sodium  bicarb. 
1  dr.  to  a  quart  of  water. 

For  a  purely  technical  consideration  of 
the  medico-legal  aspects  of  this  subject,  we 
recommend  the  reader  to  the  many  excel- 
lent works  published  on  Medical  Juris- 
prudence. 


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